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A TEXT-BOOK 



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PRACTICAL THERAPEUTICS 



WITH ESPECIAL REFERENCE TO THE 



APPLICATION OF REMEDIAL MEASURES TO DISEASE 



AND THEIR 



EMPLOYMENT UPON A RATIONAL BASIS 



BY 

HOBART AMORY HARE, M.D., LL.D., B.Sc. 

PROFESSOR OF THERAPEUTICS, MATERIA MEDICA, AND DIAGNOSIS IN THE JEFFERSON 

MEDICAL COLLEGE OF PHILADELPHIA; PHYSICIAN TO THE JEFFERSON MEDICAL 

COLLEGE HOSPITAL; ONE-TIME CLINICAL PROFESSOR OF DISEASES OF 

CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA; COMMANDER, 

U. S. N. R. F. 



EIGHTEENTH EDITION 



ENLARGED, THOROUGHLY REVISED AND LARGELY REWRITTEN 
ILLUSTRATED WITH 144 ENGRAVINGS AND 6 PLATES 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1922 




.w* 



\0^ 



rAe object of this book is to place the subject of treatment before the 
reader so that it may be applied at the bedside in a rational manner. 
The endeavor of the true physician is: 
" To cure sometimes, to relieve often, to comfort always" 



Copyright, 1922, by Lea & Febiger 



The use in this volume of certain portions of the text of the United States 
Pharmacopoeia is by virtue of permission received from the Board of Trustees of 
the United States Pharmacopoeia! Convention. The said Board of Trustees is 
not responsible for any inaccuracy nor for any errors in the statement of quantities 
or percentage strengths. 



PRINTED IN U. S. A. 

JAN -9 192? 

©CU654178 



>Vo | 



PREFACE TO EIGHTEENTH EDITION. 



When a book has reached its eighteenth edition it should be 
revised more thoroughly than ever before. In order that it may 
represent modern therapeutics it should be gone over by the author 
so thoroughly that the publisher will find it impossible to use the old 
plates and must set it up in new type. These things have been done. 
In the preparation of the text the same constant endeavor has been 
made as heretofore to meet the needs of the man actually dealing 
with patients, who wants to know what to do, how to do it and how 
results are to be best obtained. As was said in the preface to the 
last edition: 

The author must hold fast to that which is good and cast aside 
that which has become obsolete, but in doing this he must not permit 
his desire to accept the new to overcome respect for the old, if the 
old has the endorsement of long experience on the part of his fellows 
and himself. 

The last thirty years have done much not only to put hitherto 
empirical methods upon a scientific basis, but to develop new plans 
of treatment and, in the repeated revisions of this book, the author 
has endeavored to include all facts that have proved their value and 
certain new ones which are still on trial but promise much, as for 
example, silver arsphen amine in syphilis, quinidine sulphate in 
auricular fibrillation, thyroxin in hypothyroidism and the use of the 
anterior lobe of the pituitary. The pages on transfusion has been 
largely rewritten, as have those dealing with renal disease. 

As in the earlier editions, so in this, the author wishes to acknowl- 
edge the kindness of his friends who have revised articles dealing with 
subjects in which they are recognized authorities, namely, Dr. G. E. 
de Schweinitz, Professor of Ophthalmology, the articles on diseases of 
the eye; Dr. Edward Martin, formerly Professor of Surgery, those on 
venereal diseases, and Dr. Barton C. Hirst, Professor of Obstetrics, 
in the University of Pennsylvania, those which touch upon the dis- 
orders of parturition or pregnancy. 

The author's thanks are once more due to a member of his staff 
Dr. Leighton F. Appleman for his care in the preparation of the 
indices. 

H. A. H. 

January, 1922, 

1801 Spruce Street, 
Philadelphia. 

(v) 



CONTENTS. 



PART I. 

General Therapeutical Considerations 17 

PART II. 
Drugs 65 



PART III. 

Remedial Measures other than Drugs. Foods for the 
Sick 537 

Feeding the Sick , 6-16 



PART IV. 

Diseases 663 

Index of Drugs and Remedial Measures 961 

Index of Diseases and Remedies 991 



( vii ) 



Comparative Table showing the Strength of the More Important Pharma- 

copoeial Substances and Preparations in the Preceding and in the 

Present Pharmacopoeia 



Title. 



i Chief Constituent 



U. S. P. 8th Revision. 



U. S. P. 9th Revision. 



Dilu- 



Acidum Aceticuni 

Dilutum . 
Benzoicum . 
Boricum 
Hydriodieum 

turn 
Hydrobromicum 
. Dilutum 
Hydrochloricum 
Hydrochloricum 

Dilutum 
Hydrocyanieum 

Dilutum 
Hypophosphorosum 

Hypophosphorosum 

Dilutum 
Lacticum 



Nitricum 
Phosphoricum . 
Phosphoricum Dilu- 
tum 
Salicylicum . 
Sulphuricum 

Aromaticum . 

Dilutum 
Trichloraceticum . 
Aconitum .... 



Acetic Acid . 

Hydriodic Acid 
Hydrobromic Acid 
Hydrochloric " 

Hydrocyanic " 

Hypophosphorous 

Acid 
Hypophosphorous 

Acid 
Lactic Acid . 



Nitric " . . 
Phosphoric Acid 



not less than 36.0 per cent. 
6.0 

no assay 

not less than 99.8 per cent. 
" 10.0 

" 10.0 



Sulphuric 



Ether-soluble alka- 
loids of aconite 



from 36.0 to 37.0 per cent. C2H4O2. 

5.7 to 6.3 
not less than 99.5 per cent. C7H6O2 
" 99.5 " H3BO3 

from 9.5 to 10.5 per cent. HI. 



.Ether . . . 
Alcohol Dilutum 



Ethyl oxide 
Alcohol . 



Alumen Exsiccatum 

Ammonii Bromidum 
" Carbonas . 

" Iodidum 
Antimonii et Potassii Tar- 

tras 
Aqua Ammonise 

" " Fortior 

Argent i Nitras . 

" Fusus 
" Oxidum . 

Arseni Iodidum . 

Asafo3tida .... 



Bismuthi et Ammonii 
Citras 
Subnitras . 
Br om of or mum . 
Caffeina Citrata 

" Effer- 
vescens 
Calcii Bromidum 

" Carbonas Prsecipi- 
tatus 
Calcii Chloridum 

Calx 

Cannabis 

Cantharis .... 

Chloralum Hvdratum . 



Ammonia 



Alcohol-soluble 
constituents 



Bismuth oxide 



Caffeine . 



Cantharidin . 



" 31.9 
" 10.0 

" 20 

" 30.0 
" 10.0 

" 75.0 
of lactic acid without 
anhydrides 
not less than 68.0 per cent. 

" 85.0 

" 10.0 

no assay 

not less than 92.5 " 

" 20.0 

" 10.0 

no assay 

not less than 0.5 per cent 
aconitine 

about 96 per cent. 

about 41.5 per cent, by 

weight 
about 48.9 per cent, by vol 

ume 
not less than 99.0 per cent. 

" 97.0 
yielding not less than 31.58 

per cent. NH3 
not less than 97.0 per cent. 

" 99.5 

" 10.0 

" 28 « 

" 99.9 

" 94.8 

" 99.8 

not less than 82.7 per cent. 

iodine 
not less than 16.3 per cent. 

arsenic 
gum-resin — not less than 50 
per cent. 



from 46 to 50 per cent. 

not less than 80 per cent. . 

99 per cent 

no assay 

not less than 97.0 per cent. 

" 99.0 

not less than 99 per cent, 

(anhydrous) 
not less than 90 per cent, 
no assay ..... 



.5 to 10.5 



31.0 to 33.0 
9.5 to 10.5 



" 30.0 to 32.0 
" 9.5 to 10.5 



HBr. 

HC1. 
HC1. 

HCN. 

H3PO2. 

H3PO2. 



lactic acid and lactic anhydrides 

equivalent to from 85 to 90 per 

cent. CsHeOs. 

from 67.0 to 69.0 per cent. HNO3. 

" 85.0 to 88.0 " H3PO4. 

" 9.5 to 10.5 " H3PO4. 

not less than 99.3 " CiHeOs. 

from 93.0 to 95.0 " H2SO4. 

" 19.0 to 21.0 " H2SO4. 

" 9.5 to 10.5 " H2SO4. 

not less than 99 per cent. C2HO2CI3. 
not less than 0.5 per cent, ether- 
soluble alkaloids; biological 
assay recommended, 
from 95.5 to 97.5 per cent.(C 2 H : )20. 
from 41.0 to 42.0 per cent, by 

weight, 
from 48.4 to 49.5 per cent, by vol- 
ume, C2H5OH. 
not less than 96.5 per cent. AIK 

(S0 4 ) 2 or AINH 4 (S04) 2 . 
not less than 98.5 per cent. NH4Br. 
yielding from 30 to 32 per cent. 

NH 3 . 
not less than 99.0 per cent. NH4I. 
" 98.5 
K(SbO)C4H 4 06+iH 2 0. 
from 9.5 to 10.5 per cent. NH 3 . 
" 27.0 to 29.0 " NH 3 . 
not less than 99.8 per cent. AgNC-3. 
" 94.5 " AgNOs. 
" 99.6 " Ag 2 0. 



99.0 



Asia. 



gum-resin — not less than 60 per 
cent, alcohol-soluble constit- 
uents. 

powder — not less than 50 per cent, 
of alcohol-soluble constituents. 

from 46 to 52 per cent. Bi 2 0-3. 

not less than 79 per cent. Bi203. 
about 96 per cent. CHBr 3 . 
not less than 48.0 per cent. 
" 1.9 



" 84.0 " CaBr 2 
(hydrated form), 
not less than 98 per cent. CaCO-3. 

not less than 75 per cent. CaCh. 
(hydrated form). 

not less than 95 per cent. CaO. 

biological assay required. 

not less than 0.6 per cent, of can- 
tharidin. 

not less than 99.5 per cent. 
C2HCI3O+H2O. 



Comparative Table showing the Strength of the More Important Pharma- 
copceial Substances and Preparations — Continued. 



Title. 



Chromii Trioxidum 



Cinchona 



Codeinae Phosphas 

Creta Praeparata 
Cupri Sulphas 



Digitalis 

Emplastrum Belladonnse 

Extractum Belladonna? 
Foliorum 
Cannabis 
Colchiei Cormi 

Hyoscyami . 

Nucis Vomicae 

Opii . . . 

Physostigmatis 

Stramonii . 

Ferri Chloridum 

et Ammonii Citras 
et Quininae " 

Sulphas .... 

Sulphas Exsiccatus 
Fluidextractum Aconiti 



Belladonnae Radicis 



Cannabis 
Cinchona? . 



Colchiei Seminis 

Digitalis 
Guaranae 



Hydrastis 

Hyoscyami . 

Ipecacuanhae 

Nucis Vomicae . 

Pilocarpi 

Scillae . . . 
Glyceritum Hydrastis 



Chief Constituent 



Guarana 



Hydrargyri Chloridum 
Mite 



Cinchona alkaloid 



Alkaloids from bel- 
ladonna leaves 

A'kaloids from bel- 
ladonna leave: 

Colchicine 

Alkaloids from hy- 

oscyamvis 
Alkaloids from nux 

vomica 
Anhydrous mor 

phine 
Alkaloids from 

physostigma 
Alkaloids from 

stramonium 
Iron .... 

" and quinine 



Ether-soluble alka 
loids from aco 
nite 

Alkaloids from bel 
ladonna root 



Cinchona alkaloids 



Colchicine 



Caffeine 



Ether-soluble alka 
loids from hy 
drastis 

Alkaloids from hy 
oscyamus 

Ether-soluble alka 

loids from ipe 

cac 
Alkaloids from nux 

vomica 
Alkaloids from 

pilocarpus 

Ether-soluble alka- 
loids from hy 
drastis 

Caffeine . 



U. S. P. 8th Revision. 



not less than 90.0 per cent. 

not less than 5.0 per cent, 
total anhydrous cin- 
chona alkaloids and at 
least 4 per cent, anhy- 
drous ether-soluble alka- 
loids 

no assay 



not less than 99.5 per cent 



leaves from plants of second 
year's growth, at com- 
mencement of flowering 

from 0.38 to 0.42 per cent. 

1.4 per cent, mydriatic alka- 
loids 

no assay 

1.4 per cent 

0.3 per cent, mydriatic alka- 
loids 
5.0 per cent, strychnine 

20.0 per cent, crystallized 
morphine 

2 per cent, ether-scluble 
alkaloids 

1 per cent, mydriatic alka- 
loids 

22 per cent. 

13 ... 

not less than 13.5 per cent, 
iron and 11.5 per cent 
dried quinine 

not less than 99.5 per cent. 



U. S. P. 9th Revision. 



not less than 95.0 per cent. Cr03. 



not less than 5.0 per cent, total 
alkaloids. 



not less than 67 per cent, anhy- 
drous codeine. 

not less than 97 per cent. CaCC>3. 

from 62.97 to 66.79 per cent, anhy- 
drous CuS04 (not less than 
98.5 per cent. CuS0 4 +5H 2 0). 

biological assay recommended. 



100 mils, contains 0.4 Gm 
of aco ni tine 



100 mils, contains 0.4 Gm. 
mydriatic alkaloids 

no assay 

100 mils, contains 4 Gm. of 
anhydrous ether-soluble 
alkaloids 

100 mils, contains 0.4 Gm 
colchicine 

no assay 

100 mils, contains 3 5 Gm 
of alkaloids from guar- 
ana 

100 mils, contains 2 Gm. hy- 
drastine 

100 mils, contains 0.075 Gm 
100 mils, contains 1.5 Gm. 



100 mils, contains 1 Gm 

strychnine 
100 mils, contains 0.4 Gm. 



not less than 3.5 per cent. 

alkaloidal principles 
not less than 99.5 per cent. 



from 0.35 to 0.40 per cent, of alka- 
loids from belladonna leaves. 

from 1.18 to 1.32 per cent, of alka- 
loids from belladonna leaves. 

biological assay required. 

from 1.25 to 1.55 per cent, of col- 
chicine. 

from 0.22 to 0.28 per cent, of the 
alkaloids from hyoseyamus. 

from 15.2 to 16.8 per cent, of alka- 
loids from nux vomica. 

from 19.5 to 20.5 per cent, of an- 
hydrous morphine. 

from 1.7 to 2.3 per cent, of the 
alkaloids from physostigma. 

from 0.9 to 1.1 per cent, of the 
alkaloids from stramonium. 

corresponding to 20 per cent. Fe. 

" to 16 to 18 per cent. Fe. 

" " 11.5 to 13 per cent. 

Fe and not less than 11.5 per 

cent, anhydrous quinine. 

from 54.36 to 57.07 per cent, anhy- 
drous FeS04 (not less than 99.5 
per cent. FeS04+7H>0). 

not less than 80 per cent, anhy- 
drous FeS04. 

100 mils, contains 0.45 to 0.55 Gm. 
of the ether-soluble alkaloids 
of aconite; biological assay 
recommended. 

100 mils, contains 0.405 to 0.495 
Gm. of the alkaloids from bella- 
donna root. 

biological assay required. 

100 mils, contains 4 to 5 Gm. of the 
alkaloids from cinchona. 

100 mils, contains 0.36 to 0.44 Gm. 

of colchicine, 
biological assay recommended. 
100 mils, contains 3.6 to 4.4 Gm. 

of caffeine. 

100 mils, contains J. 8 to 2.2 Gm. 
of the ether-soluble alkaloids. 

100 mils, contains 0.055 to 0.075 
Gm. of the alkaloids from hyos- 
eyamus. 

100 mils, contains 1.8 to 2.2 Gm. 
of the ether-soluble alkaloids 
from ipecac. 

100 mils, contains 2.37 to 2 63 Gm. 
of alkaloids from nux vomica. 

100 mils, contains 0.55 to 0.65 Gm. 
of the alkaloids from pilocarpus. 

biological assay recommended. 

100 mils, contains 1.12 to 1.37 Gm. 
of the ether-soluble alkaloids 
from hydrastis. 

not less than 4 per cent, of oaffeine. 

not less than 99.6 per cent. HgCl. 



Comparative Table showing the Strength of the More Important Pharma- 
copoeial Substances and Preparations— Co ntinued. 



Title. 



Chief Constituent. U. S. P. Sth Revision. 



U. S. P. 9th Revision. 



Hydrargyri Iodidum! 

Flavum 

Rubrum . . I 

Hydrargyrum . . . i 

cum Creta . | 

Hyoscyamus . . . 

Iodum .... 
Jalap 



Linimentum Camphorae 

Liquor Acidi Arsenosi . i 

Arseni et Hydrargyri 

Iodidi 
Ferri ChloriJi . . 

Subsulphatis . 

Tersulphatis . 

Iodi Compositus 
Magnesii Citratis . 

Plumbi Subacetatis 

Potassii Arsenitis . 



Hydroxidi . 
Sodse Chlorinatae 
Sodii Arsenatis 

Hydroxidi . 
Zinci Chloridi 
Lithium Bromidum 

Magnesii Carbonas . 



Mercury . 
Alkaloids from hy- 
oscyamus 

Resins of jalap 



Camphor 
Arsenic trioxide . 

{ 

Ferric Chloride . 

Basic ferric sul- 
phate 

Normal ferric sul- 
phate 

Iodine . . A 

Magnesium citrate 

Lead subacetate 

Potassium arsenite 



not less than 99.5 per cent. 



38 per cent 

not less than 0.08 per cent. 

99 per cent 

not less than 7 per cent, total 
resin, of which not more 
than 15 per cent, should 
be soluble in ether 

20 per cent j 

corresponding to 1 per cent. 

1 per cent, arsenous iodide 
1 " mercuric iodide 
corresponding to 10 per 

cent, of iron 
corresponding to not less 

than 13.57 per cent, of> 

iron 
corresponding to not less 

than 10 per cent, of iron 
5 per cent, iodine . 
10 " potassium iodide 
no 



not less than 99.0 per cent. Hgl. 



99.0 



Hgl2 

Hg. 



Oxidum 



Ponderosum 
Sulphas . 



Maltum .... 

Massa Ferri Carbonatis 

Hydrargyri . 
Methylis Salicylas . 

Xux Vomica . . . , 

Oleum Cajuputi 

Cari ....". 




from 37 to 39 per cent. Hg. 

not less than 0.065 per cent, of the 

alkaloids from hyoscyamus. 
99.5 per cent, iodine, 
not less than 7 per cent, total 

resins of jalap. 



from 19.5 to 20.5 per cent, of cam- 
phor. 

corresponding to 0.975 to 1.025 
per cent. AS2O3. 

from 0.95 to 1.05 per cent. AsL. 
" 0.95 to 1.05 " Hgl 2 . 

corresponding to 10 to 11 per cent. 
Fe. 

corresponding to 13 to 14 per cent. 
Fe. 

corresponding to 10 to 11 per cent. 

Fe. 
from 4.8 to 5.2 per cent, iodine. 

" 9.8 to 10.2 " KI. 
corresponding to not less than 1.5 

Gm. MgO in 100 mils, 
lead subacetate corresponding to 

not less than 18 per cent. Pb. 
potassium arsenite corresponding 

to 0.975 to 1.025 per cent. 

AS2O3. 
not less than 4.5 per cent. KOH. 

" 2.5 
from 0.975 to 1.025 per cent. 

Xa2HAs0 4 . 
not less than 4.5 per cent. XaOH. 

48.5 to 52 per cent, 
not less than S5 per cent. LiBr. 



Caryophylli 

Cassise (Oleum Cin- 

namomi U. S. P. 

VIII) 

Eucalypti . 

Mentha? Piperita? . 



Viridis 
Opii Pulvis . 

Opium 



Mercury- 



Alkaloids from nux 

vomica . 
Cineol . . . 
Carvone . 

Eugenol . . . 
Cinnamic aldehyde 



Eucalyptol 
Menthol . 



Carvone . 
Morphine 



not less than 25 per cent, of 

lead subacetate 
potassium arsenite corre- 
sponding to 1 per cent, 
of arsenic trioxide 
about 5 per cent. ... 
at least 2.4 per cent. . . I 
not less than 1 per cent, ex- 
siccated salt 
about 5 per cent. ... 

" 50 ' " . . . 

not less than 97 per cent. 

when dried 

magnesium carbonate corre-j magnesium carbonate and hydrox- 

sponding to not less ide corresponding to not less 

than 38.4 per cent, of than 39.2 per cent. MgO and 

magnesium oxide not more than 0.8 per cent. 

CaO. 

not less than 96 per cent. . not less than 96 per cent. MgO, 

nor more than 2 per cent. CaO. 

same as magnesii oxidum . same as magnesii oxidum. 

not less than 99.7 per cent, from 48.59 to 53.45 per cent, anhy- 

crystallized salt drous MgSOi (not less than 

99.5 per cent. MgS04 + 7H 2 0). 

no assay capable of converting 5 times its 

weight of starch into sugars. 

" not less than 35 per cent. FeC03. 

33 per cent from 32 to 34 per cent, of Hg. 

no assay not less than 98 per cent. 

CH3C7H5O3. 
not less than 1.25 per cent, not less than 2.5 per cent, of the 

strychnine alkaloids of nux vomica, 

not less than 55 per cent. no assay. 

no assay not less than 50 per cent, of car- 
vone. 
not less than 80 per cent. . not less than 82 per cent, of eugenol 
" " 75 " . not less than 80 per cent, of cinna- 
mic aldehyde. 



" 50 

not less than 6 per cent, of 
esters calculated as men- 
thyl acetate and not less 
than 50 per cent, of total 
menthol 

no assay 

12 to 12.5 per cent, crystal- 
lized morphine 

not less than 9 per cent, 
crystallized morphine 



not less than 70 per cent, of (euca- 
lyptol) cineol. 

not less than 5 per cent, of esters 
calculated as C10H19C2H3O2 
and not less than 50 per cent, 
of CioH 19 OH. 

not less than 43 per cent. 

10 to 10.5 per cent, anhydrous 
morphine. 

not less than 9.5 per cent, anhy- 
drous morphine. 



Comparative Table showing the Strength of the More Important Pharma- 
copceial Substances and Preparations— Continued. 



Title. Chief Constituent. 


U. S. P. 8th Revision. 


U. S. P. 9th Revision. 


Opium Deodoratum . Morphine 


12 to 12.5 per cent, crys- 


10 to 10.5 per cent, anhydrous 






tallized morphine 


morphine. 


Granulatum 


" 


12 to 12.5 per cent, crys- 


10 to 10.5 per cent, anhydrous 






tallized morphine 


morphine. 


Phenol 




not less than 98.0 per cent. 


not less than 97 per cent. CeHsOH. 


Liquefactum 




" 86.4 " 


" " 87 " CeHsOH. 




phenol 




Phosphorus .... 




not less than 99.5 per cent. 


no assay. 


Pilocarpus .... 


Alkaloids from 


0.5 per cent 


0.6 per cent, of the alkaloids from 




pilocarpus 




pilocarpus. 


Pilula? Ferri Carbonatis 




no assay 


each pill contains not less than 
0.06 Gm. FeCOs. 






Plumbi Acetas . . 




not less than 99.5 per cent. 


from 85.31 to 89.57 per cent anhy- 
drous Pb(C 2 H 3 02) 2 (not less 
than 99.5 per cent Pb(G>H 3 02)2 
+3H 2 0). 


Podophyllum 


Resin of podophyl- 
lum 


no assay 


not less than 3.0 per cent, of resin. 


Potassii Acetas . 


not less than 98.0 per cent. 


" 99.0 " KC2H.3O2. 


Bitartras 




" 99.0 


" 99.5 " KHC4H4O6. 


Bromidum 




" 97.0 


not less than 98.5 per cent. KBr. 


Carbonas 




" 98.0 


" 99.0 " K2CO.3. 


et Sodii Tartras 




" 99.0 


from 73.71 to 77.39 per cent, of an- 
hydrous KNaCifLOti (not less 
than 99 per cent. KNaCir^Oe 
+4H2O). 


Pulvis Effervescens Com- 




no assay 


from 23 to 27 per cent, sodium bi- 


positus .... 






carbonate; from 73 to 78 per 
cent, potassium and sodium 
tartrate. 


Resorcinol .... 







not less than 99.5 per cent. C0H4 
(OH) 2 . 


Scilla 




" 


biological assay recommended. 


Sodii Acetas .... 




not less than 99.5 per cent. 


from 59.97 to 62.96 per cent, anhy- 
drous NaC2H302 (not less than 
99.5 per cent. NaC2H 3 2 + 
3H 2 0). 


Arsenas .... 




" 98.0 


from 58.98 to 61.92 per cent, anhy- 
drous Na2HAs04 (not less than 
99 per cent. Na 2 HAs04+7H 2 0). 


Boras .... 




" 99.0 


from 52.32 to 54.92 per cent, anhy- 
drous Na2B40? (not less than 
99 per cent. N^BjOr+lOrfcO). 


Bromidum . 




« 970 


not less than 98.5 per cent. NaBr. 


Citras .... 




" 970 


, " " 98.0 

NasCeHoO: +2H 2 0. 


Iodidum 




" 98.0 


not less than 99.0 per cent. Nal. 


Nitris .... 




" 90.0 


" 95.0 " NaNO>. 


Phenolsulphonas 




" 99.0 


from 83.64 to 87.82 per cent, anhy- 




drous NaCeHoO.SOs (not less 








than 99 per cent. NaCeHoO.SO* 








+2H2O). 


Phosphas 




" 99.0 " 


from 39.25 to 44 per cent, anhy- 
drous Na2HP04 (not less than 
99 per cent. Na 2 HP04-r-12H20). 


Exsiccatus 




" 99.0 
" 99.0 


not less than 98 per cent. Na2HP04. 


Sulphas .... 




from 43.64 to 48 per cent, anhy- 








drous Na2S04 (not less than 99 








per cent. Na2SO4 + 10H 2 O). 


Thiosulphas 




" 98.0 


from 63.07 to 67.48 per cent, anhy- 






drous Na2S20 3 (not less than 99 








per cent. Na2S203+5H20). 


Spiritus ^Etheris Nitrosi 


Ethyl nitrite 


" 4.0 


from 3.5 to 4.5 per cent, C2H5NO2. 


Glycerylis Nitratis 


Glyceryl trinitrate 


1 per cent 


from 1.0 to 1.1 percent. GsHotNOsJs. 


Strontii Bromidum . 




not less than 97.0 per cent. 


not less than 98 per cent. SrBr> + 






6H2O. 


Iodidum 




" 98.0 


not less than 99 per cent. SrL> + 
6H2O. 


Salicylas 




" 98.5 


not less than 99 per cent. 
Sr(C7H=0 3 )2+2H20. 


Strophanthus 




no assay 


biological assay recommended. 


Sulphur Sublimatum 




not less than 99 per cent. . 
no assay 


not less than 99.5 per cent, sulphur. 


Suprarenalum Siccum 




from 0.4 to 0.6 per cent, epineph- 


(Glandulse Supra- 






rine; biological assay recom- 


renales Siccse U. S. P. 
VIII) 
Syrupus Acidi Hydriodici 






mended. 


Hydriodic Acid . 


about 1 per cent, or about 


100 mils, contains 1.3 to 1.45 Gm. 






1.19 Gm. in 100 mils. 


HI. 


Ferri Iodidi 


Ferrous Iodide . 


about 5 per cent, or about 
6.74 Gm. in 100 mils. 


from 4.75 to 5.25 per cent. Fel2. 


Thymolis Iodidum . 


Iodine 


45 per cent 


not less than 43 per cent, iodine. 



Comparative Table showing the Strength of the More Important Pharma- 
copoeial Substances and Preparations — Continued. 



Title. 



Chief Constituent. 1 U. S. P. 8th Revision. 



U. 8. P. 9th Revision. 



Thyroideum Siccum 

(Glandulae Thyroidese 
Sicca? U. S. P. VIII) 

Tinctura Aconiti 



Belladonnse Foliorum 



Cannabis 
Cinehonse 



Composita 

Colchici Seminis 

Digitalis 

Ferri Chloridi . 

Hydrastis . 
Hyoscyami . 
Iodi .... 
Nucis Vomicae . 
Opii .... 
Deodorati . 
Physostigmatis 



Scillae 
Stramonii 



Strophanthi 
Unguentum Hydrargyri 
Dilutum 

Phenolis 
Zinei Acetas . 



Iodine 



Ether-soluble alka- 
loids from aco- 
nite 

Alkaloids from bel- 
ladonna leaves 



no assay 



100 mils, contains 0.045 Gm 
aconitine 



100 mils, contains 0.03 Gm 



no assay 

Alkaloids from cin J 100 mils, contains 0.75 Gm 
chona anhydrous ether-soluble 

alkaloids 

Alkaloids from cin- no assay 

chona 
Colchicine . . 100 mils, contains 0.04 Gm. 



Ferric Chloride . 



Ether-soluble alka- 
loids from hy- 
drastis 

Alkaloids from hy- 
oscyamus 



no assay 

13.28 per cent, anhydrous 

salt, corresponding to 

4.6 (4.58) per cent, met-; 

allic iron 
100 mils, contains 0.4 Gm. 

hydrastine 

100 mils, contains 0.007 Gin. 
mydriatic alkaloids 



100 mils, contains 7 Gm. of 
iodine and 5 Gm. of 
potassium iodide 
Alkaloids from nuxi 100 mils, contains 0.1 Gm. 
vomica strychnine 



Morphine 



Alkaloids from 
physostigma 



100 mils, contains 1.2 to 1.25 
Gm. crystallized mor- 
phine 

100 mils, contains 1.2 to 1.25 
Gm. crystallized mor- 
phine 

100 mils, contains 0.014 Gm. 
ether-soluble alkaloids 



no assay 

Alkaloids from 100 mils, contains 0.025 Gm. 



stramonium 



mydriatic alkaloids 



Mercury 
Phenol 



no assay 

not less than 49 per cent, 
about 33 per cent. . 

3 per cent 

not less than 99.5 per cent. 



Carbonas Praecipita- j corresponding to not less 

tus than 72 per cent, zinc 

oxide 



Chloridum . 
Phenolsulphonas 



Stearas 
Sulphas 




not less than 99.5 per cent. 
" 99.5 



no assay 

not less than 99.5 per cent. 



from 0.17 to 0.23 per cent, iodine 
in thyroid combination. 

100 mils, contains 0.045 to 0.055 
Gm. of the ether-soluble alka- 
loids from aconite; biological 
assay recommended. 

100 mils, contains 0.027 to 0.033 
Gm. of the alkaloids from bella- 
donna leaves. 

biological assay required. 

100 mils, contains 9.9 to 1.1 Gm. 
of the alkaloids from cinchona. 

100 mils, contains 0.45 to 0.55 Gm. 
of the alkaloids from cinchona. 

100 mils, contains 0.036 to 0.044 
Gm. of colchicine. 

biological assay recommended. 

about 13 per cent. FeCb, corre- 
sponding to not less than 4.48 
per cent. Fe. 

100 mils, contains 0.36 to 0.44 Gm. 

of the ether-soluble alkaloids 

from hydrastis. 
100 mils, contains 0.0055 to 0.0075 

Gm. of the alkaloids from hyos- 

cyamus. 
100 mils, contains 6.5 to 7.5 Gm. of 

iodine and 4.5 to 5.5 Gm. KI. 

100 mils, contains 0.237 to 0.263 
Gm. of the alkaloids of nux 
vomica. 

100 mils, contains 0.95 to 1.05 Gm. 
anhydrous morphine. 

100 mils, contains 0.95 to 1.05 Gm. 
anhydrous morphine. 

100 mils, contains 0.013 to 0.017 
Gm. of the alkaloids from phy- 
sostigma. 

biological assav recommended. 

100 mils, contains 0.0225 to 0.0275 
Gm. of the alkaloids from stra- 
monium. 

biological assay recommended. 

from 49 to 51 per cent. Hg. 
" 29 to 31 " Hg. 

about 2 per cent. 

from 83.16 to 87.32 per cent, anhy- 
drous Zn(C2H 3 0-2)2 (not less 
than 99.5 per cent. ZntCsHjOsja 
+2H 2 0). 

corresponding to not less than 68 
per cent. ZnO. 

not less than 95. per cent. ZnCl2. 

from 73.7 to 77.4 per cent, anhy- 
drous Zn(C,HoO.S03)2 (not 
less than 99.5 per cent. Zn 
(C 6 HoO.S0 3 )2+8H 2 0). 

corresponding to 13 to 15.5 per 
cent. ZnO. 

from 55.86 to 58.65 per cent, anhy- 
drous ZnSO-t (not less than 99.5 
per cent. ZnSC>4 +7H2O.) 



DRUGS WITHDRAWN FROM THE BRITISH PHARMACOPOEIA. 



The General Medical Council of Great Britain has issued an official 
announcement to doctors and chemists, which alters the British 
Pharmacopoeia, 1914. Until further notice there are withdrawn from 
the Pharmacopoeia, the medicines and compounds, and the directions 
for preparing them, set forth in the following schedule, the medicines 
and compounds ceasing to be included among official preparations 
of The British Pharmacopoeia, 1914, until legal order respecting them 
is made : 

All confections, except confectio piper is, confectio rosse gallicse. 

All glycerina, except glycerinum. 

All mistura?, except mistura creta*, mistura ferri composita, mistura 
olei ricini. 

All syrupi, except syrupus, syrupus chloral, syrupus codeinse phos- 
phatis, syrupus ferri iodidi, syrupus ferri phosphatis cum quinina et 
strychnina, syrupus glucosi. 

All trochisci, except trochiscus krameria? et cocainee, trochiscus 
morphine, trochiscus morphina 3 et ipecacuanha?. 

All caffeinse citras effervescens, decoctum aloes compositum, extrac- 
tum gossypii, radicis corticis liquidum, linimentum potassi iodidi cum 
sapone, liquor calcis saccharatus, magnesii sulphas effervescens, mel 
boracis, pulvis amygdalae compositus, pulvis glycyrrhiza? compositus, 
pulvis tragacantha? compositus, sodii citrotartras effervescens, sup- 
positoria glycerini, tinctura cardamomi composita, tinctura kino, 
tinctura pruni virginianae, tinctura rhei composita, tinctura senna? 
composita, unguentum iodi. 



( xiv ) 



PART I. 

GENERAL THERAPEUTICAL CONSIDERATIONS, 



Before entering into a study of the action of drugs upon the 
living body, it is necessary that the student should possess a clear idea 
that the word "therapeutics" means the treatment of disease, that 
he should comprehend fully the reason why resort is had to remedial 
measures, and, more important than all, that he should grasp the 
limitations which govern the administration of remedies. He should 
never forget, as student and practitioner, the following rules: 

When called to guide a patient through an illness the physician should 
be constantly a watchman, and a therapeutist only ichen necessity arises. 

A good physician is one who having pure drugs knoivs when to use 
them, how to use them, and, equally important, tchen not to use them. 

Any drug which has the power to do good ivhen rightly used, has 
the power to do harm if wrongly used. 

When a physician gives a drug and the patient improves, care should 
be taken not to ascribe all tlie good results to the remedy employed. 
Nature must be given credit for a large part of the improvement. 

In the sixteenth century Ambroise Pare, the father of modern surgery, 
wrote, "I dressed him; God cured him." 

The physician should always remember that variations from the 
normal in certain cases of disease may be efforts of Nature to meet 
the needs of the patient. Increased rapidity of respiration in fever is 
an endeavor on the part of the body to get rid of heat, and in the dog, 
for example, this method of cooling the blood by rapid breathing is 
his chief means of doing this. So too rapid respiration may not only 
be an endeavor to get rid of CO2, but it enables the blood to carry 
oxygen to the tissues so that toxic matters may be the better destroyed. 
Constant cough may not only be desirable to get rid of profuse 
secretion or pus, but to empty bronchial or pulmonary cavities of 
material which, if retained, may cause disaster. Again, cough in 
the presence of a failing circulation may be an effort to obtain the 
assistance of the respiratory pump in aiding circulation in the great 
veins of the thoracic cavity. Anasarca may be an effort to maintain 
the normal tonicity of the body fluids when the kidneys cannot 
eliminate the normal quantity of salt. There is too great a tendency 
to believe that variations in healthy function in the presence of dis- 
ease are enemies to be fought by the ministrations of the physician. 
2 (17) 



18 GENERAL THERAPEUTICAL CONSIDERATIONS 

There are those who deride the use of drugs. Such persons 
have never used them or have used them improperly. The man 
who does not believe in the proper use of remedies lacks the very 
keystone of the arch upon which all medical investigation rests, for 
the ultimate aim and object of all medical thought and effort is 
the cure or alleviation of disease. Like other things requiring a 
thorough knowledge of their component parts, methods of treatment 
are often much abused by the careless and ignorant, but are a power 
for good in the hand of the properly educated physician. Further 
than this, therapeutics is the only universally used part of medicine, 
for each and every branch must resort to it. 

The first duty of the physician when called to a case of illness is to 
reach a diagnosis as to the cause of the ailment, and not until he has 
formed a definite idea as to the condition which confronts him should 
he prescribe any medicinal agent. In certain cases where the symp- 
toms are severe or indicative of immediate danger it may be necessary 
to give relief by the use of temporary remedies, not only to save life, 
but also to remove symptoms which, because of their severity, mask 
the condition so that a diagnosis is impossible. Thus, a patient may 
be found in collapse or in a state of syncope. The cause of this state 
may be obscure, but the pulse, heart-sounds, and respiratory action 
may indicate the need of immediate stimulation. In another instance 
agonizing pain, as that due to a crisis in locomotor ataxia, or renal or 
hepatic colic, may require a hypodermic injection of morphine as 
soon as the physician assures himself that the pain complained of is 
genuine. In other instances the case may be so obscure that several 
days of careful study may be necessary to reach a correct diagnosis, 
and during this time palliative remedies may be required. 

Before ordering a drug or method of treatment the physician should 
have a clear conception of what he is trying to accomplish. No 
remedy should be given unless there is a distinct indication for its use. 
The old-fashioned " shot-gun" prescription, containing many ingredi- 
ents, one or more of which might hit the mark, should be supplanted 
by the small-calibre rifle-ball sent with directness at the condition to 
be relieved. 

Having decided upon the remedy indicated, the physician must 
next determine the dose required. This latter decision is almost as 
important as the first, for very often an error in dosage will cause 
failure of the remedy. A large part of the therapeutic skill of the 
physician consists in fitting the dose to the needs of his patient. 

In the treatment of all forms of disease the physician must never 
forget the following influential factors in the case, which are often of 
greater importance than the measures devoted to the treatment of the 
disease itself: 

1. The maintenance of vital resistance by proper feeding. 

2. The elimination of effete materials by the kidneys, bowels, and 
skin. 



GENERAL THERAPEUTICAL CONSIDERATIONS 19 

3. The relief of annoying symptoms which sap the patient's vitality 
and often obscure the true state of the system. 

4. That sufficient physical and mental rest and sleep are obtained 
if possible. 

1. That the proper use of food in both acute and chronic illness is of 
great importance is not only manifest, but it has been proved by 
scientific investigation that lack of food often prevents the system 
from successfully combating the entrance and growth of infecting 
microorganisms. The patient who has a greatly lowered vital resist- 
ance not only suffers from the effects of the particular disease by 
which he has been attacked, but not rarely dies from the growth of 
other microorganisms which find him a fair mark for their attacks, 
thereby producing what Flexner has well called "terminal infec- 
tions," and causing Osier to say that "a man rarely dies of the disease 
from which he is suffering," meaning by this that though he may be 
ill of a specific infection, other germs really produce the fatal issue. 
Care in feeding is therefore never to be ignored, and the various 
ways of feeding and preparing foods must be carefully studied. (See 
Part III.) 

2. It would seem hardly necessary to insist on the importance of 
maintaining the active elimination of impurities from the body were 
it not that so little attention is paid by some physicians to these func- 
tions. In all infectious diseases the kidneys are required not only to 
eliminate the ordinary waste products of the body, which usually 
escape in this way, but in addition the increased waste produced by 
the fever and the poisons produced directly and indirectly by the 
growth of the invading microorganisms. It is essential therefore that 
the patient shall pass urine in sufficient amount to carry off these sub- 
stances, and this result often may be obtained by giving plenty of 
water to drink and increasing diuresis by the use of sweet spirit of 
nitre and citrate or acetate of potassium. Nor is it sufficient to 
determine that the quantity of urine is normal. Repeated esti- 
mations of the solids should be made in all serious cases, to ascertain 
whether the eliminating function of the kidney is active, for some- 
times the flow of urine is sufficient, but the quantity of urinary 
solids is far below what it should be. Not rarely in disease, and 
even in apparent health, the patient states that his bowels have 
moved daily, and the physician is content with this report with- 
out making inquiries as to the quantity of the feces or whether 
the quantity is adequate in regard to the amount of food ingested. 
Even when the bowels are moved daily we may find after some 
days that there has been a partial retention of fecal matter, so 
that the colon becomes filled with feces. Sometimes moderate diar- 
rhea is an effort of Nature to eliminate poisons, and is to be regarded 
as an aid to the patient, and not to be arrested by constipating 
remedies. It is also to be recalled that one of the functions of 
the liver is the elimination and destruction of toxic materials, and 



20 GENERAL THERAPEUTICAL CONSIDERATIONS 

therefore the use of a cholagogue not only unloads the bowels, but 
also aids the liver in one of its most important duties. As the skin 
is an important eliminating organ, it must be kept clean by frequent 
washing, and if inactive it must be stimulated to increased activity by 
rubbing, and in some cases by hot packs or Turkish baths. (See 
Heat.) 

3. It is of importance, as already stated, that symptoms which 
accompany the progress of various forms of diseases should be modi- 
fied or removed if they become sufficiently active to produce much 
discomfort or disturb the patient's rest. Headache, backache, itch- 
ing, wind colic, etc., can often be entirely removed by simple means 
and sometimes without the internal use of drugs. It is, on the one 
hand, important to avoid unnecessary discomfort; and, on the other, 
care must be taken that in the use of remedies to relieve annoying 
symptoms we do not mask important diagnostic factors in the case or 
influence unfavorably the course of the malady. Thus in appendicitis 
it is wise, as a rule, not to give morphine to relieve the pain, as it will 
quiet the patient so as to lead him and his attendants to regard the 
condition as actually healed, when in reality the pathological process 
is rapidly progressing. Only when the pain is agonizing ought suffi- 
cient of the drug be given to allay the excess of pain, and never 
enough to mask the real condition. It is of vital importance that the 
physician be not content with the relief of symptoms alone, but that 
he should regard them as of comparatively little importance, while 
he searches for and tries to remedy the diseased state itself. Thus, it 
would be folly to treat the headache of uraemia and fail to treat the 
cause producing it. 

Not infrequently care is not taken to discover whether the patient 
has sufficient sleep or rest. It is perfectly true that if a sick man lies 
awake an hour he is apt to believe he has been awake all night; but, 
on the other hand, in severe illness prolonged actual wakefulness is a 
very exhausting feature of the attack. Every one of experience has 
seen cases rally when apparently in a most serious state, and conval- 
esce when a good sleep has been given them by the aid of judiciously 
used drugs. If the- patient is getting about the normal amount of 
sleep in the twenty-four hours, hypnotics should be avoided as if 
they were poisons. 

THE MODES OF ACTION OF DRUGS/ 

To understand the mode of action of remedial measures it is 
essential to recall the facts upon which our practice of therapeutics 
is based. From the earliest times in the history of mankind an 
endeavor has been made to alleviate and cure disease, and for thou- 
sands of years the only reason for applying a remedy in a given 
case rested upon the belief, not necessarily the fact, that it had done 
good in an earlier case which presented a similar chain of symptoms 



MODES OF ACTION OF DRUGS 21 

or signs. It is manifest that this plan is open to many errors. 
First, the fact that the patient got better after a given plan of treat- 
ment is not a proof in itself that the remedy did the good work. 
It is possible that the patient would have gotten well if left alone. 
Second, the physician and the patient in studying the symptoms may 
very readily misinterpret them, the more so as one patient may place 
great emphasis on one series of symptoms and another patient 
magnify other symptoms which to him may seem of great impor- 
tance, whereas they are, in reality, of little value. Third, as no two 
human beings react in an identical manner to the influence of dis- 
ease or remedies, what may be advantageous to one may not be to 
another. Fourth, a remedy which may be of the greatest value at 
one stage of a malady may be useless or even harmful at another. 
All these factors, therefore, stand in the way of obtaining accuracy 
by treatment based on the principle that because "A" has been 
bettered, "B" will be benefited by the same plan. It is not to be 
forgotten, however, that some of these elements of uncertainty can 
be, and are, eliminated if the physician has experience which enables 
him to properly weigh the conditions which he sees or feels, and if 
his experience enables him to attach proper weight to the statements 
of the patient or his friends as to the conditions present. Again, 
if a plan of treatment does good in a large series of cases identical 
in character, it is justifiable assumption that its effects are real. 
A very large and invaluable part of our methods of treatment at 
present must rest upon the results of clinical observation for obvi- 
ous reasons, and for the additional reasons that until the biologist, 
physiologist, pathologist, and bacteriologist can tell us as to what 
life is, what disease is, and how both life and disease occur, we 
cannot explain how a plan of treatment, proved beyond all doubt 
efficacious, acts. Therapeutics must rest, now and for all time, to 
some extent upon what bedside experience has taught, and this 
experience is so large that it is of inestimable value. 

At times in the past because of lack of knowledge of the functions 
of the body and the cause and course of disease, erroneous ideas 
have developed, particularly when a large series of successful cases 
led to the belief that a plan of treatment did good, when, in reality, 
it was valueless. With the discovery that the plan was an error, 
particularly if the treatment was disagreeable or vigorous, a revulsion 
of feeling occurred, and medical men leaped to the conclusion that 
because this plan was wrong all plans of treatment were wrong, and, 
therefore, worthless, with the result that they became therapeutic 
agnostics or therapeutic nihilists, than which there is no more miser- 
able object in the presence of disease. At a time when excessive 
mistaken medication had reached such a point, through the desire 
of the physician to do good and the demand of the patient that 
something be done, that actual harm often resulted, these therapeutic 
nihilists became divided into two factions : one that said " we can do 



22 GENERAL THERAPEUTICAL CONSIDERATIONS 

nothing," and the other, with more knowledge of human nature, who 
really did nothing, but pretended that they did something because 
they found that mankind insisted upon at least thinking that efforts 
were being made in its behalf. Led by a clever itinerant theorist, 
named Hahnemann, they developed the idea of infinitesimal doses, 
and as these doses were too small to produce any influence, the patient 
had a chance to get well without having to fight the disease and mis- 
taken efforts in his behalf. Hahnemann's plan of treatment was 
based, however, on just as little knowledge of disease and of how 
drugs acted as that of his predecessors, and was more erroneous 
because, in addition to his ignorance, he developed a lot of mistaken 
ideas which he evolved out of his inner consciousness, as, for example, 
that by diluting, grinding, or shaking a drug one could actually 
increase its power over the functions of the body. 

The next step came with the advance of chemistry that give us 
new drugs and active principles of old ones, so that their complex 
effects could be better separated, understood, and employed, and 
simultaneously physiology and pathology began to discover facts 
which made our conceptions of the functions of the body more 
clear and, therefore, improved our idea as to what happened in disease. 
Before this the morbid anatomist had shown us what the conditions 
were after death, but this gave only a sidelight upon the processes 
during life. In general terms, the conception of the living body as 
an aggregation of living cells may be considered to have been the 
first step toward the more rational therapeutics of today. This 
conception of the cells of the body has resulted in many therapeutic 
advances which will be shortly referred to. 

The recognition of the fact that the body is an aggregation of 
living cells was shortly followed by the knowledge that, through 
differentiation and special development, each cell has its own par- 
ticular function to perform, and when this function is perverted or 
arrested illness or death ensues. It also became evident that as 
cells became highly differentiated as to function and form, they 
became susceptible to influences which failed to affect other special 
cells, and knowledge of this fact gave impetus to the next step 
toward modern therapeutics, because this explained why certain 
remedies acted upon one part of the body and not on others. 

The physical, chemical, and physiological state of the cells of the 
body may exercise a bearing on the effect of medicinal or poisonous 
substances. If this is true, we find that the cells of the body may 
possess properties which render them immune to the effects of such 
compounds, whether these compounds remain intact or are broken up. 
Thus, immunity or insusceptibility may be due to the fact that the 
composition of the cell may be so stable that the drug cannot destroy 
it. Its envelope may resist penetration of the drug or, even if it is 
unable to resist penetration, its protoplasm may be of such a nature 
that the drug is not soluble in it. As an example of permeability we 



MODES OF ACTION OF DRUGS 23 

find that the renal cells are permeable to the sulphates; whereas, the 
cells of the intestinal mucous membrane are impermeable to these 
compounds. Thus, magnesium sulphate taken by the mouth in a 
strong solution remains in the bowel and acts only as a purge. If 
injected in full amount into the blood it is a powerful poison. 

The relationship of ions to the effect of inorganic drugs on the 
body has not been fully determined. When an electrolyte goes 
into solution some of its ions are set free, and, being charged with 
positive or negative electricity, on coming in contact with, or entering, 
the cells thereby produce certain effects or changes— as, for example, 
stimulation or depression— by altering their electrical state. 

Again, certain cells of the body, although they may be suscepti- 
ble to a given substance if kept continuously in contact with it, 
nevertheless escape, because it is no sooner taken up than it is cast 
out. 

Many cells otherwise susceptible escape because they have the 
power of oxidizing the substance or of otherwise destroying it before 
it can do harm. This is the explanation of the fact that alcoholics 
and those who have the morphine habit are able to tolerate doses 
which would kill an ordinary man. In other words, their cells 
have had their oxidizing powers greatly increased by training. Again, 
in some manner which we do not understand, cells of the body 
possess the power of becoming accustomed to the presence of a 
given substance, provided its amount at first is not so great that 
the cell is destroyed at once. How this is accomplished we do not 
know. In some instances, particularly if a chemical compound be 
organic and of the nature of a protein poison, the cells protect them- 
selves by producing antitoxin. (See Antitoxin.) So far as we know, 
antitoxins are not formed to combine with ordinary chemical com- 
pounds. 

Conversely, the chemical constitution or function of a cell may 
render it especially susceptible to a given agent, in that its com- 
ponent part or parts have an affinity for one or all of the molecules 
forming the compound, as in the case of ether and chloroform, which 
combine with the lipoid or fatty portion of the cells of the higher 
nervous system and cause anesthesia. 

In other instances, a cell suffers not because the agent primarily 
is deleterious, but because the cell stores it until its quantity renders 
it poisonous in effect. So, too, cells may be affected because the com- 
pound hydrates or dehydrates, solidifies or liquefies them, or they 
are influenced by the drug because it dissolves out some essential 
constituent, as, for example, cholesterin or lecithin. The process 
of hydration or dehydration is usually due to the fact that a given 
substance possesses hygroscopic properties, as glycerin, for example, 
or it results in obedience to the law of osmosis. Thus, if the pro- 
portion of salts in a fluid surrounding a cell is identical with the 
proportion of the salts in a cell, no change occurs; that is, the fluid 



24 GENERAL THERAPEUTICAL CONSIDERATIONS 

and the cell contents are isotonic. If the proportion of salts in the 
fluid is less than that of the cell (hypotonic), it abstracts salt from the 
cell until the content of cell and fluid is identical ; whereas, if the salt 
content of the fluid is in excess (hypertonic), the fluid passes out of the 
cell until the proportions in cell and fluid are equal or isotonic. Cer- 
tain substances which in themselves are practically of little power 
may, therefore, act as very powerful agents because of their dilution 
or concentration. Thus, sulphate of magnesium, given in strong 
solution to a patient with dropsy, causes profuse watery dejections 
because, being highly concentrated, it causes the dehydration of the 
water-logged tissues, the fluid in which pours into the bowel to make 
the magnesium solution as dilute as the juices of the body. If, how- 
ever, the magnesium solution is not concentrated and the patient is 
lacking fluid because of prolonged thirst, the magnesium salt may be 
absorbed into the blood and produce poisonous effects. 

Again, certain cells have so-called receptors, or handles, by which 
they become attached to the drug, which thereby influences them. 
This is particularly true in the case of complex protein poisons, as 
the toxin of diphtheria or tetanus, for example, and it is also a fact 
in the case of many chemical compounds made synthetically. (See 
below.) Indeed, according to some investigators, the action of 
morphine in causing sleep is due to the fact that the cells of the brain 
possess receptors for it just as the cells of the anterior cornua of the 
spinal cord possess receptors which unite with strychnine. It is 
doubtful if this is true, however, as to ordinary alkaloids. 

The structure of the cell, anatomical or chemical, renders it 
susceptible to certain substances. This is illustrated by the fact 
that methylene blue stains axis cylinders and sensory nerve-end- 
ings, whereas it fails to stain motor nerve-endings. Furthermore, 
certain cells are not stained by a given dye in health, but are stained 
when diseased, and it is well known in practical therapeutics that 
there is a great variation in the effects of remedies upon cells in health 
and disease. 

The result of all these influences is that cells may be altered in 
function; that is, stimulated, depressed, or perverted. They may 
also suffer organic changes which result in temporary arrest of 
function or in death. 

Last of all, it must be recalled that the susceptibility of cells 
depends, in many instances, solely upon their vitality, for many 
substances which affect living cells fail to affect or enter dead cells, 
and vice versa. This is probably due to some change in the ana- 
tomical or chemical construction of the cell, and in some instances 
it is probably due to the presence of oxygen in or about the living 
cell. Thus, paraphenylenediamine when injected into the blood 
deeply stains brown the central tendon of the diaphragm, the muscles 
of the eye, larynx, and tongue. This is because the cells in these 
areas are so highly endowed with bloodvessels that they contain an 



MODES OF ACTION OF DRUGS 25 

excess of oxygen, and not because the cells have any special predilec- 
tion for the dye. Ehrlich believed that susceptibility is also influenced 
by the chemical environment of the cell, not only as to oxygen, but as 
to the alkaline and acid reaction. 

It is seen, therefore, that the cell doctrine gave us our first clear 
conception of vital function, and that it, with the study of the 
functions of special aggregations of cells, or cell physiology, has led 
us to the understanding of the physiological effect of many remedies. 

It is evident that a medicinal substance may exert an influence on 
the body in many different ways. First, it may act in its original 
form upon those cells of the body which have a special affinity for 
it, or, on the other hand, it may be inactive until it is split up in 
the body into two or more of its component parts, one or all of 
which act on one variety of cells or on different varieties of cells. 
This is illustrated when we administer potassium bromide, potassium 
iodide, or potassium cyanide, for in the body the bromine, iodine, or 
cyanogen is set free and acts powerfully; whereas the potassium 
base produces little or no effect. Much depends upon the readiness 
with which this breaking up occurs. Some compounds soon split 
up in toto, whereas others give up but little of their active com- 
ponent. Thus, in the case of iodoform the proportion of iodine 
readily liberated is 90. G per cent.; that of iodol, 50 per cent.; that 
of europhen, only 28.5 per cent. 

Again, the various component parts of a drug may be dissociated, 
and then form a new compound or compounds which produce a 
physiological effect not possessed by the substance as originally 
given. In the case of hexamethylenamin, commonly called urotro- 
pin, the therapeutic effect of the drug is not exercised as uro tropin, 
but as formaldehyde, which is excreted in many secretions, acting 
as an antiseptic. In other instances, such dissociation having 
taken place, one or more of the component parts unites with some 
substance which exists in the body and forms a new and active 
compound. 

Furthermore, the readiness with which a drug is dissolved or 
broken up in the organism greatly affects the quickness and sever- 
ity of its influence. As illustrative of this fact we find that phena- 
cetin and acetanilid do not act as such, but only after they have 
become changed into paramidophenol by oxidation, and as phenacetin 
undergoes this change more slowly than acetanilid, it is less powerful 
as a drug and less active when given in poisonous dose. 

Perhaps no better illustration of the activity of a drug, depending 
upon the readiness with which it is dissolved and broken up in the 
body, can be cited than the members of the nitrite group, in which 
amyl nitrite acts instantly, nitroglycerin acts a little more slowly, 
nitrite of sodium and nitrite of potassium still more slowly, and 
erythrol tetranitrate more slowly than all the others. In each 
instance the action is identical in kind, but different in degree, because 



26 GENERAL THERAPEUTICAL CONSIDERATIONS 

of the chemical stability of each compound. Conversely, it is to 
be recalled that many substances which possess a chemical formula 
indicative at first sight of great physiological power are nevertheless 
inert because they are so stable that they are not broken up in the 
body, as, for example, ferrocyanide of potassium, in which neither 
the iron nor hydrocyanic acid exercise any effect because, although 
the latter is by itself a deadly poison, the chemical compound is 
indissoluble in the body. 

At one time it was thought that there might be a definite rela- 
tionship between chemical constitution and physiological action, but 
this has proved incorrect, so far as universal application is concerned. 
It is, however, possible by changing the chemical formula of a sub- 
stance to greatly alter its physiological influence, not only in degree, 
but in kind, and to such an extent that it will no longer affect one 
part of the body, but will influence parts which, in its original form, 
it did not touch. 

There is not space to discuss this in detail, but the following illus- 
trations will suffice. Caffeine, which is trimethylxan thine, increases 
the functional activity of the heart, the respiratory center, the brain, 
and the muscles, and possesses a moderate stimulant effect on the 
kidneys; whereas, theobromin, which is dimethylxanthine, that is, 
contains one less methyl molecule, has little effect upon any part of 
the body except the kidneys, which it powerfully stimulates. So, 
too, propyl alcohol (C3H7OH) is more narcotic than ethyl alcohol 
(C2H5OH) and ethyl alcohol is more narcotic than methyl alcohol 
(CH3OH), the addition of one molecule of carbon and two of hydro- 
gen in each instance increasing the power of the compound. In 
the celebrated research of Baumann and Kast they found that sul- 
phones not decomposed in the body are inactive, and that those 
which are decomposed when combined with one or more methyl 
groups are likewise inactive; whereas, if one or more ethyl groups 
are substituted they become powerful hypnotics, as sulphonal, trional, 
and tetronal. 

Progress along another line resulted from a recognition of the 
fact that many of the disorders of function in the body, and actual 
disease, came about because of the presence, within or without, of 
hitherto undreamed of particles of protoplasm or cells, now called 
microorganisms, or bacteria, or parasites, which directly, or by pro- 
ducing poisons during their life or after their death, destroyed the 
cells of the body of man as completely as more manifest destructive 
agents. With this discovery it became clear that the function of 
the physician was to aid the patient in combating or withstanding 
their attacks, and also to destroy these malign agents if possible. 
In other words, it was learned that the aggregation of cells called 
the living body was aligned in disease against an aggregation of 
other cells, or invaders, or parasites, that sought to live by preying 
upon that body. 



MODES OF ACTION OF DRUGS 27 

Having made these discoveries and having observed that many 
men and animals recovered when attacked by bacteria or other para- 
sites, it became evident that the aggregation of cells called the body 
must be, in many instances, capable of protecting themselves against 
its enemies, and it became the duty of the investigator to discover 
what these protective methods are. It was soon found that the juices 
of the body and particularly the secretions or products of certain 
tissues, as, for example, the blood-serum and lymph, destroyed and 
dissolved invading germs or parasites (bacteriolysis); that certain 
cells of the body, notably certain of the white blood-cells, sur- 
rounded, or swallowed, certain germs and devoured them (phago- 
cytosis) (see Vaccine Therapy), and that a barrier of lymph and 
cells, which rapidly became organized into tissue, walled off the 
seat of invasion from the rest of the body. Further, that the lymph 
nodes are designed to provide forts or outworks in which hosts of 
devouring white cells battle with invading parasites that get so far. 
It was found that the cells of the body produce some substance or 
substances, as yet not isolated, which render invading parasites unable 
to cope with the phagocytes or white cells (opsonins). These facts 
having been determined, it was soon discovered how the physician 
can stimulate these protective processes to increased activity, as is 
shown in the text of this book later on. (See Vaccine Therapy.) 

It was also noted that certain animals were immune to the action 
of certain microorganisms or their poisons which destroyed man, 
and, therefore, it became evident that such animals must be an 
unfavorable site for their growth; that is, possessed of the power 
of destroying the invading germs or parasites, or of antidoting 
the poisons they produced after they gained access to the body. 
The idea then followed that by injecting the blood serum of an 
immune animal into a living body not immune, some of the immunity 
of the animal could be conferred on the man, and this proving true 
the first step in antitoxin treatment of disease was taken. 

The sum of all this advance is that at present we can aid the 
body in its endeavor to live by increasing bacteriolysis, by render- 
ing the germs easy of slaughter by the white cells (Vaccine Therapy), 
and by stimulating the cells of an immune animal to increased 
activity we produce an antidote to bacterial or other toxins. (See 
Antitoxins.) 

So far we have considered only the measures by which the body 
can be aided so that it will directly or indirectly combat the attack of 
parasites or their effects. It still remains to discover what can be done 
to destroy such parasites by giving remedies which will, because of the 
peculiarities of the protoplasm of these invaders, be able to destroy 
them without detroying the cells of the host. Until recently it was 
found that any substance capable of destroying the life of the proto- 
plasm of the invader destroyed the more highly specialized and vital- 
ized protoplasm of the man or animal. 



28 GENERAL THERAPEUTICAL CONSIDERATIONS 

It is manifest that if certain drugs have a special affinity for certain 
cells in the body, it is probable that there are discoverable substances 
which will have a special affinity for invading cells, and, by attacking 
them exclusively, destroy them alone. To the task of obtaining these 
substances Ehrlich and his co-workers have set themselves, with bril- 
liant results. Ehrlich started out with the hypothesis that for any 
substance to act upon a cell it must become intimately connected with 
it or fixed in it, and that this fixing, or marriage of the cell and the 
substance, can only take place by virtue of the fact that the cell has a 
receptor, or hand, by which it may be attacked or grasped. The re- 
ceptor which takes the chemical substance is called a chemoceptor. It 
follows, therefore, that only those cells which have a receptor fitted to 
grasp a given chemical agent can be effected by it. On this basis he 
sought to find drugs which would unite with the protoplasm of an 
invading parasite, but be unable to damage the body cells, since 
they would have no receptors by which the poison could attach itself 
to them; that is, substances that would be parasitotropic and not 
organotropic. Further than this, he believed, and he proved, that not 
only a single substance could be so used, but that if he formed several 
groups of chemical substances into one fairly firmly connected com- 
pound, the cell of an invading parasite, by having a receptor for only 
one group, would nevertheless fall a victim to all the members of the 
group, although all the other members of the group might have been 
unable to unite with the cell if by themselves. It is as if several 
thieves who could not gain the confidence of a householder, finally 
joined together with another thief, who could worm his way into the 
householder's confidence, and having done so, permit the others to 
prey upon him; or, to use Ehrlich's own terms, the compound may 
be likened to a dart, the tip of which enters the body and the 
shaft of which connects the farther end laden with poison with the 
wound. Thus, in the case of arsphenamine, described below, which is 
dioxydiamidoarsenobenzol, the excess of the orthoamidophenol fixes 
the drug to the parasite, and so the trivalent arsenic group is enabled 
to reach the arseno-receptor of the cell of the spirochseta. But the 
beneficial effect does not stop here, for the destruction of the parasites 
results in the formation of antibodies, which also destroy any spiro- 
chetal which may have escaped. 

There is not space to describe in detail Ehrlich's work, but, begin- 
ning with the parasite known as the trypanosome, Ehrlich tried the 
effect of various compounds, and found that those of the benzidine 
series destroyed it, particularly one which is red in hue and which he 
called, in consequence, "Trypan Red." Unfortunately this dye, 
although it destroyed the trypanosome, also destroyed the host of 
the parasite. He also found that atoxyl destroyed this parasite, and 
while less toxic to the host than trypan red, still was deleterious 
because the cells of the optic and acoustic centers contained chemo- 



LIMITATIONS OF THERAPEUTICS 29 

ceptors for this compound. His next endeavor was to produce a 
compound which would combine with the receptor of the trypano- 
some, but with none of the cells of the host, and after a time produced 
arsacetin, which was nevertheless capable of being united with some 
of the cells of the host. After making 418 compounds, he obtained 
arsenophenylglycin, which was still less hurtful to the infected 
animal, but yet toxic to a small degree. This compound not only 
killed trypanosomes, but spirilla, as those of relapsing fever and 
chicken spirillosis. Next, he produced, as his six hundredth and sixth 
product, "606," which not only acts on the parasites named as well 
or better than its predecessors, but destroys the Spirochseta pallida 
or parasite of syphilis. This compound, dioxydiamidoarsenobenzol, 
has little toxic power over the body, but is not entirely innocuous, 
and since then Ehrlich has improved it in this respect, producing 
neoarsphenamine "914" (see Part II), a compound which is not quite 
harmless to man, but possessed of an extraordinary affinity for the 
parasite of syphilis; so great an affinity that one large dose may be 
capable of destroying every spirochseta in the body of an animal. 
Unfortunately one dose is rarely sufficient in man. Ehrlich stated 
that if iodine is introduced into arsphenamine it increases its effect on 
spirochseta of syphilis and diminishes its effect on trypanosomes, so 
that by varying the chemical constitution of a compound it may be 
made more specific. Ehrlich's work has, therefore, given us a specific 
remedy for syphilis, yaws, relapsing fever, African sleeping-sickness, 
and holds promise of much more. It could not have been accom- 
plished without the knowledge of the cells of the body, the advances 
of bacteriology and chemistry, or without his extraordinary ability 
and training. 

These facts show that therapeutics, with many other branches of 
medical learning, has emerged from pure empiricism into scientific 
accuracy, and stimulate us to aid in the advance and in the practice 
of accurate methods of treatment. 



THE LIMITATIONS OF THERAPEUTICS. 

It is of vital importance that the physician should also bear in mind 
the physiology and pathology, or abnormal physiology, of the various 
organs that he is called upon to treat. By doing so he will clearly 
recognize that failure to get the results he desires may be inevitable 
and in no way casts doubt upon his judgment as to the use of the 
remedy or upon its ability to do good, if this is possible. Because of 
the remarkable reparative processes of the body, particularly in the 
young, results can often be obtained which the devotee of the autopsy 
table believes to be impossible. Such a devotee is not a student of 
abnormal or perverted physiological function, but of morbid anatomy. 



30 GENERAL THERAPEUTICAL CONSIDERATIONS 

Perverted function may arise from disordered action or actual organic 
change which in turn may be beyond relief. As a rule, cases of per- 
verted function dependent upon no permanent organic change give 
the best results. It is therefore of the greatest importance that as clear 
a conception as possible of the state of an organ be obtained before 
one attempts to place a value upon a remedy which is seemingly 
indicated. Thus in a case of cardiac failure due to valvular lesions, 
digitalis may give the most brilliant results because the heart muscle 
is not in many cases diseased but only weary. In another instance 
digitalis may woefully fail because the myocardium is so degenerated 
that there is little normal heart muscle to be influenced. Again, we 
have the problem of the value of arsphenamine in syphilis. This 
drug undoubtedly kills the parasite of the disease but we have no 
right to expect it to clear up the damage already produced by the 
existence of the parasite in the tissues for months or years. There is 
no more reason for condemning 606 under these conditions than there 
is in expressing the belief that water is useless in the presence of a fire 
because while it puts out smouldering embers it is unable to rebuild 
the partly destroyed building. There are limits, in other words, as to 
what we can do by remedial measure as there are limits to every 
other line of human endeavor. Quinine may destroy the parasite of 
malaria just as 606 destroyes that of syphilis, but in one sense both 
drugs are rather prophylactics than curative agents because they 
utterly fail to correct the lesions which the parasites have induced. 
In other cases the toxin of one of the acute infections produces a 
perversion of function or an actual lesion which completely nullifies 
the usual effects of a remedy. The limitations of therapeutics are 
therefore not so much the results of impotency on the part of remedies 
as they are due to the fact that irremediable degenerations have 
occurred. 



DIRECT AND INDIRECT ACTION OF DRUGS. 

Drugs act in two ways, which are sometimes called near and 
remote, direct and indirect. The near, or direct, action of a drug is 
that influence which is felt by the exercise of its effect directly upon 
the tissues with which it comes in contact; the indirect, or remote, 
influence is that result which comes as a sequence of its primary 
effect. As an illustration of this we may take the local use of can- 
tharides. The local, near, or direct effect of this is a blister; the 
remote or indirect effect is the absorption of exudates or the influ- 
encing of inflammatory processes. If a purge is used, its direct 
effect is the purgation which ensues, while its indirect effect is the 
relief of dropsy through the removal of transudate. 



MODES OF ADMINISTERING DRUGS 31 



MODES OF ADMINISTERING DRUGS. 

Drugs may be administered for trie purpose of affecting the general 
system in many ways, but practically we employ only nine methods, 
as follows : 

1. By the mouth or stomach. 

2. By hypodermic injection. 

3. By intravenous injection. 

4. By intramuscular injection. 

5. By inhalation. 

6. By the rectum. 

7. By inunction. 

8. By fumigation. 

9. By sublingual medication. 

By the Mouth.— By far the most usual manner of administering 
drugs is by way of the mouth, which is the natural means of entrance 
into the body for foreign substances. Whenever medicines are used 
in this way the physician should clearly bear in mind what the 
medicine is to do after it is swallowed. If the drug is intended 
to act directly upon the stomach, it should not be given after meals, 
but some time before, since the food and gastric juice may afterward 
so cover the gastric mucous membrane that the medicament cannot 
act upon it. Thus, in a case of chronic gastric catarrh or gastric 
ulcer, the nitrate of silver which is used should always be given half 
an hour or an hour before meals. On the other hand, if an ulcer or 
other trouble exists in the small intestine, the pill should be given 
some time after meals, and if a heavy meal is taken, four or five hours 
after, since under these circumstances the medicine is swept out into 
the intestine almost at once, without remaining any time in the 
stomach, where it may be chemically altered. Very often it is neces- 
sary to give a medicine soon after food is taken in order that it may 
not act in too powerful or concentrated a manner upon the viscus 
which receives it or upon the general system by reason of its rapid 
absorption in concentrated form. 

The general rule, however, may be laid down that all medicines 
are to be taken after rather than before meals, unless a local gastric 
effect or very rapid absorption is desired. 

It is worthy of note that soluble tablets or drops placed under the 
tongue are absorbed almost as rapidly as if given hypodermically. 
This is called " sublingual medication." 

By Hypodermic Injection.— Next to the use of drugs by the mouth, 
by far the most popular method is their administration by means of 
the hypodermic needle and syringe. The logic of this method rests 
upon the absorption of all soluble substances from the subcutaneous 
tissues with great rapidity. Any substance soluble enough or sus- 
pendable enough to pass through a hypodermic needle without form- 



32 



GENERAL THERAPEUTICAL CONSIDERATIONS 



ing an obstruction may be employed, provided it is not too irritating 
and that it is "clean." 

The proper places to give such injections are the forearm, on the 
extensor surface, 1 the deltoid area of the arm, the abdominal wall, 
over or into the pectoral muscles, or the broad of the back— in other 
words, any spot where the tissues are not dense and unyielding. The 
skin of the part is to be grasped or pinched up with the thumb and 
forefinger of the left hand and the needle sent well into this raised 
fold, preferably above the finger and thumb, so that the pressure of 
the fingers may prevent pain and hold the part steady. The needle 




Fig. 1. — Method of giving a hypodermic injection. The skin having been steril- 
ized, the needle is then pushed into the subcutaneous tissues, as shown in the illustra- 
tion. If the injection is given into the forearm, the skin of the "part into which the 
injection is to be given is to be raised by grasping it between the thumb and fingers 
of the left hand to aid in holding the forearm steady. 

should always penetrate well into the loose connective tissue, so that 
the liquid injection may find lodgment in the relaxed and spongy 
subcutaneous tissues without separating the skin from its rather 
close adhesions to the tissues below or from the bloodvessels supplying 
it, for if separation occurs abscess and a slough may result. 

The dangers from hypodermic injections are chiefly two. First: 
The needle may enter a vein, and the entire dose be carried at once, 
en masse, to the vital centers. Second: The solution or needle used 
may not be sterile, and an abscess result. The first danger is to be 
avoided by injecting into parts not well supplied with veins, and the 



1 Hypodermic injection into the flexor aspect of the forearm often causes much 
pain in the hand by irritating temporarily the branches of the radial or ulnar nerves. 



MODES OF ADMINISTERING DRUGS 33 

second by thoroughly washing both syringe and needle with alcohol 
and then with sterile water the instant before they are used. The 
solution injected should be prepared by using freshly boiled water. 
Most physicians now make a solution for immediate use by adding a 
small tablet of the required drug to 20 mi aims of water at the moment 
it is needed or resort to ampoules containing a sterile solution of the 
medicament. A third danger supposed to exist by some persons, 
but probably more feared than need be, is the injection of air into a 
vein with the medicament. It is well to see that all air is expelled 
from the syringe before making the injection. Most hypodermic 
syringes hold from twenty to thirty minims. 

By Intravenous Injection.— The intravenous injection of drugs is 
rarely practised except in the use of arsphenamine or neoarsphena- 
mine in the treatment of syphilis or of quinine in the treatment of 
malarial infection. Needless to state only substances capable of 
complete solution can be so used. If at all irritating in character the 
drug must be well diluted and if the bulk of the injection is large the 
solution should be warm. If the drug used possesses much effect 
on the heart or vital centers the injection must be given slowly. 
(See Intravenous Injection, Part III.) In adults such injections are 
nearly always given by the median cephalic or the median basilic 
veins in the arm. In young infants the injection by a vein in the arm 
is difficult and the longitudinal sinus is usually employed. (See Also 
Intra-abdominal Injections, Part III.) The advantage of an intra- 
venous injection is that it acts promptly and one is sure that a full 
effect of a given dose is attained, whereas when a drug is given by the 
stomach or hypodermic needle much of the injection may be unab- 
sorbed for an indefinite period. 

By Intramuscular Injection.— Meltzer and Auer have shown that the 
rapidity of the absorption of a drug when given by the hypodermic 
needle is greatly increased if it be injected into the belly of one of the 
larger muscles. This rapidity of action almost equals that of an intra- 
venous injection. Certain substances too irritating for hypodermic 
use are also given into the muscles. 

By the Rectum.— When drugs are given by the rectum, we employ 
them for three purposes: first, to influence the general system by their 
absorption; secondly, to act locally upon any disease which may be 
present in this particular locality or in the colon; and, finally, to dis- 
lodge substances or parasites which it is desired to bring away. The 
word " enema" is loosely used to denote all these injections, be their 
purpose what they may, and is synonymous with "rectal injection" 
or the more old-fashioned word "clyster." Sometimes these injec- 
tions are called "lavements." If nourishment is being given, the 
injection is called a "nutrient enema." The efficiency of medication 
by the rectum depends greatly upon the character of the substance 
injected. When foodstuffs are given in this way, in all probability 
little more than their salts and fluids are absorbed. When very 
3 



34 GENERAL THERAPEUTICAL CONSIDERATIONS 

soluble alkaloids, such as strychnine sulphate is used, the absorption 
is very rapid and complete. 

In this mode of administration it is very necessary that the physi- 
cian should use the medicaments in proper bulk; and it may be laid 
down as a rule that no more liquid should be injected than is neces- 
sary to convey the medicine or food unless the injection is for the 
purpose of emptying the bowel of fecal matter or other materials, or 
it be desired to distend the bowel in order to overcome obstruction, 
or to influence the colon by drugs. 

The reason for this lies in the fact that any large bulk of liquid 
sent into the rectum so stimulates the walls by distention as to cause 
spasmodic contraction, with expulsion of all the rectal contents, which 
is just what is needed when fecal matter is to be removed, but the 
opposite of what is desired when retention of a remedy or food is 
necessary for absorption or local action. In rectal catarrh or ulcers 
two to four ounces of liquid are usually sufficient in an adult to 
accomplish any medicinal influence locally or by absorption, while 
as a laxative enema one to two pints may be employed. 

By the use of injections the rectum frequently becomes irritable, 
and resists all efforts to force the entrance of liquids or solids. This is 
to be avoided by giving the injection so gently that the bowel fails to 
recognize, as it were, the entrance of the liquid, and by introducing a 
few drops of oil and laudanum in each injection. 

A large amount of distress often follows the gradual accumulation 
of fecal masses in the colon which are not passed with the daily move- 
ment of the lower bowel. These can readily be removed by large 
injections of warm water or oil or by the use of medicated liquids. 

When a large quantity of water is used, it should be warmed to 
100° F. or a little more, and it is well to add salt to it, so that it 
will represent the normal saline strength of blood-serum, namely, 
0.9 per cent. (For use of injections in special diseases, see Part IV, 
and for Enteroclysis, Part III.) 

Suppositories are another means by which medicines are introduced 
into the bowel, either for local effect or to act, after absorption of 
their contents, upon the general system. 

By Inhalation.— When drugs are given by inhalation they are gen- 
erally employed with the object of affecting the respiratory tract 
alone ; notable exceptions are ether, chloroform, nitrous oxide gas, and 
other volatile substances. Aside from anesthetics are such remedial 
measures as the inhaling of steam laden with the drugs employed, 
the respiring of air charged with the fumes of the medicament, or the 
inhalation of gases, and last, and most commonly resorted to of all, 
the use of the vaporizer, which, if properly made and employed, so 
minutely divides the liquid containing the medicament that the 
inspired air carries it to the farthest bronchiole and pulmonary 
vesicle. (See Part III.) 



MODES OF ADMINISTERING DRUGS 35 

As an example of the rules governing the administration of drugs in 
this manner we find that compound tincture of benzoin may be taken 
by inhaling the steam arising from hot water containing it, but cannot 
be used in a spray because it occludes the fine points of the atomizing 
tubes. In a similar manner the smoke of belladonna or tobacco-leaves 
may be inhaled to relieve asthma, or the fumes of chloride of ammo- 
nium for bronchitis in its later stages. Fumigation with mercury, 
the sublimed vapor being inhaled, is also useful in syphilis. Finally, 
we find that oxygen is sometimes very useful, the gas being readily 
inhaled, with good results in proper cases. 

The "spray" or atomizer is made in two forms— one form of appa- 
ratus being operated through the agency of compressed air, the other 
through the escape of steam from a small boiler. Very few of the 
compressed-air atomizers throw a spray sufficiently fine to reach the 
deeper parts of the lungs, particularly if the air is compressed by the 
hand; but all instrument makers now sell vaporizers or nebulizers 
which so minutely divide the liquid medicament that it readily enters 
the deeper parts of the lungs. 

The inhalation of moist air is very useful in bronchitis, and greatly 
aids other remedial measures. Steam may be disengaged in a room 
by means of a kettle of boiling water or by placing pieces of unslaked 
lime in a pan of water. 

By Inunction.— Inunctions consist in the rubbing into the skin of 
medicines, generally of an oily or fatty nature, or which assume this 
character through embodiment with oil or fat. Fatty substances are 
absorbed through the skin by way of the sebaceous glands, not 
through the epiderm, and, therefore, substances not fatty are but 
poorly absorbed when applied by inunction. The three substances 
most commonly used in this way are cod-liver oil, mercurial oint- 
ment, and iodine ointment. They should always be applied on some 
part where the derm is thin and well supplied with subcutaneous 
lymphatics, as in the axillse, the groins, or the insides of the thighs. 
Other substances have been and may be used by inunction; but as 
this method is necessarily a disagreeable and dirty one, it is rarely 
resorted to unless the stomach is disordered or it is necessary to cause 
absorption of the drug by every possible avenue of entrance. 

The endermic method consists in the use of a blister, by means of 
which the epiderm is raised, when a little morphine or other alkaloid 
may be slipped under it and so absorbed through the true skin. It 
is a painful method, almost never to be resorted to, having been 
supplanted by the hypodermic method of medication. 

Drugs are also sometimes caused to enter the body through the skin 
by placing them in plasters or poultices, or by the electrical process 
called cataphoresis. 



36 GENERAL THERAPEUTICAL CONSIDERATIONS 

PHARMACEUTICAL PREPARATIONS. 

Remedies are administered in a number of forms, but chiefly as 
follows : 

Abstracts are dry powdered extracts mixed with sugar of milk 
until they are twice as strong as the crude drug. Abstracts are no 
longer official in the United States Pharmacopoeia. 

Aceta, or vinegars, are solutions of the active principles of drugs 
in vinegar or dilute acetic acid. There is one in the United States 
Pharmacopoeia (Acetum Scillce) and three in the British (Acetum 
Cantharidini, Acetum Urginea and Acetum Scillce). 

Alkaloids are organic bases, forming salts with acid radicals, gen- 
erally occurring in crystalline form and abstracted from crude drugs. 
They nearly always represent the active principle of the drug. 

Aqtle, or waters, are used as vehicles either for the dilution of 
strong medicines or for the purpose of carrying minute amounts of 
flavoring materials. 

Cataplasms are not official in the United States Pharmacopoeia. 
They are virtually poultices made of linseed-meal or of bread-crumbs. 

Cerates are ointments containing wax to render them harder than 
would ordinary fats. 

Charts, or papers, consist of bibulous paper soaked in a solution 
of the drug which they are intended to carry. 

Confections are sometimes called electuaries or conserves, and 
are soft pastes which contain the drug mixed with sugar or honey. 

Decoctions are solutions of drugs made by boiling and then strain- 
ing while hot. 

Elixirs are sweetened alcoholic liquids rendered pleasant to the 
taste by the addition of aromatic substances and sugar. 

Emplastra, or plasters, are made up of adhesive substances placed 
upon a backing of cloth or leather and designed to adhere to the skin 
being so applied for the purpose of holding a medicinal substance in 
contact with the body, of acting as a protective, or of aiding in the 
approximation of the edges of a wound. 

Emulsions are liquid preparations which consist of oily substances 
minutely subdivided and held in suspension in water usually by some 
gummy material. 

Extracts consist of the soluble parts of plants reduced to a semi- 
solid or solid condition by evaporation; the soluble constituents being 
taken from the plant by water or alcohol. 

Fluid-extracts are alcoholic solutions made in such a way that 
each cc equals 1 gram of the crude drug. 

Glycerita, or glycerites, are solutions of various substances in 
glycerin— the glycerin being used as a vehicle. 

Infusions are made by pouring boiling water on the crude drug 
and allowing it to stand for a short time until the water cools, after 
which the liquid is strained. Sometimes cold water is employed. 



WEIGHTS AND MEASURES 37 

Liniments are made of oily substances often mixed with powerful 
drugs to increase their efficiency. 

Liquors are usually watery solutions of non-volatile drugs. 

Mixtures are composed of two or more drugs or of a single drug 
partly dissolved and partly in suspension. 

Pills are small round masses which, as a general rule, should not 
weigh more than three grains, in order to avoid too great bulk. If 
the material is a heavy one, as much as five grains may be placed in 
each pill. Pills may be without covering or coated with sugar or 
gelatin to preserve them and prevent the patient from tasting their 
contents. Sugar-coated pills must always be fresh and the sugar- 
coating pure. Gelatin is the best coating for pills. Many pills are 
fraudulently coated with varnish and are insoluble. 

Spirits are alcoholic solutions of volatile substances. 

Suppositories are small masses made into a cone shape and having 
for their basis cacao butter. They are designed to carry into the 
rectum certain medicines for absorption into the system or for local 
action. 

Syrups are solutions of sugar in water or in medicated aqueous 
liquids. They are used as vehicles. 

Tablets.— Under this name manufacturing pharmacists and 
others prepare compressed pills or lozenges, generally of small size, 
the mass being made to adhere by means of its being subjected to 
great pressure by special machinery. Smaller tablets are used for 
carrying powerful drugs for hypodermic use. These, however, are 
often only lightly pressed, so as to render them easily soluble. 

Tinctures are solutions of the active principles of drugs in alcohol 
or in mixtures of alcohol and water. 

Triturates are made by adding 10 per cent, of the active medi- 
cine to 90 per cent, of milk-sugar. These are then carefully rubbed 
together until the two are intimately mixed. Triturates are valuable 
in the administration of medicines to adults or to children. These 
triturates are often made into tablets, forming what are known as 
"Tablet Triturates." 

Troches, or lozenges, are flat, hardened, medicated masses designed 
to be held in the mouth, so that they may be slowly dissolved, thereby 
affecting the local mucous membrane. 

Unguenta, or ointments are unctuous preparations containing 
medicinal substances which melt at the temperature of the body. 

Wines are made in the same way as tinctures— strong white wine 
being used in the United States, and sherry or orange wine in Great 
Britain, in place of ordinary alcohol. 

WEIGHTS AND MEASURES. 

There are two systems of weights and measures employed in the 
United States at the present time. The one most commonly used 



38 GENERAL THERAPEUTICAL CONSIDERATIONS 

is the old-fashioned system of Apothecary weights for solids, and the 
Wine, or Apothecary, measures for liquids. The newer and more 
accurate system is that known as the Metric, or Decimal system of 
weights and measures, which is now recognized and recommended by 
the Pharmacopoeias of the United States, Great Britain, Germany, 
and France. 

The divisions of Apothecary weights are the pound, the ounce, 
the dram, the scruple, and the grain. The scruple, which equals 
20 grains, has dropped out of use, chiefly because the scruple mark 
when written somewhat resembles that of the dram. We may say, 
therefore, that the Apothecary weights consist of a pound, equalling 
12 ounces, or 96 drams, or 5760 grains; that the ounce represents 8 
drams, or 480 grains; and that the dram equals 60 grains. The 
abbreviation for the word grain is "gr."; for the dram, 3; for the 
ounce, § ; and the pound lb. 

In the Wine, or Apothecary, measures we have the gallon, the pint, 
the fluidounce, the fluidram, and the minim. In each gallon there 
are 8 pints, 128 fluidounces, 1024 fluidrams, and 61,440 minims. 
In each pint there are 16 fluidounces, 128 fluidrams, and 7680 
minims. In each ounce there are 8 fluidrams and 480 minims. 
In each dram there are 60 minims. The abbreviation of the Latin 
word "minimum" or "minim" is TTL; of the fluidram, f3; of the 
fluidounce, f § ; of a pint, or "octarius," O; and of the gallon, or 
"congius," Cong. 

The British Pharmacopoeia has adopted the Avoirdupois system 
of weights, and thereby has a system which differs somewhat from 
the Apothecary weights of the United States Pharmacopoeia. The 
Avoirdupois pound represents 16 ounces, or 7000 grains; the Avoir- 
dupois ounce, 437.5 grains. It will be seen, therefore, that the 
Apothecary pound contains 1240 grains less than the Avoirdupois 
pound, but that the Apothecary ounce contains 42^ grains more 
than the Avoirdupois ounce. Fortunately, however, the grain, both 
of the Apothecary and Avoirdupois systems, is of identical value. 
So, too, the British Pharmacopoeia uses what is known as the Im- 
perial system of measures in place of the Wine measures used in the 
United States. Thus, the Imperial gallon represents 8 pints, 160 
fluidounces, 1280 fluidrams, and 76,800 minims; the Imperial pint, 
20 fluidounces, 160 fluidrams, and 9600 minims; and the fluid- 
ounce, 8 drams or 480 minims. The fluidram equals 60 minims. 
It will be seen, therefore, that the Imperial measure differs from 
the wine measure chiefly in having 20 fluidounces in each pint, 
instead of 16. So, too, the weight of the Imperial fluidounce contains 
the same number of grains as the Avoirdupois ounce, which is 18.2 
grains less than the weight of the United States fluidounce, which is 
455.7. These differences between the weights and measures used in 
the United States and Great Britain are, therefore, of little import- 
ance when we are employing grains or minims, but they become of 



WEIGHTS AND MEASURES 39 

great importance when we employ ounces, and of still greater import- 
ance when we employ pounds or pints. In the average prescription, 
however, which rarely exceeds three or four ounces, the difference in 
quantities in the United States and Great Britain are not of very 
great importance. 

The advantages of the metric system over these irregular systems 
of weights and measures are the same as those of the decimal system 
of currency over the English system of pounds, shillings and pence. 
The unit of all calculations is the meter, which in the metric system 
is the unit of length. From this is derived the unit of capacity, the 
liter, which is the cube of one-tenth of a meter; and from the liter is 
derived the unit of weight, the gram, which is the one-thousandth 
part of the weight of a liter of distilled water at its maximum density. 
As a matter of fact, the metric system is no more difficult to master 
than is the system of dollars and cents. The great difficulty is that 
the majority of physicians have learned the doses of various prepara- 
tions in the Apothecary weight find it difficult to begin using the 
metric system, and do not take the trouble to convert the Apothecary 
doses into this system. 

In the metric system we have the gram (Gm.) which may be said 
to be the equivalent of the dollar; the decigram, or one-tenth of a 
gram, which represents the dime; the centigram, or one-hundredth 
of a gram, which represents the cent; the milligram, or the one- 
thousandth of a gram, which represents the mill. Above the gram 
in quantity we use what is known as the decagram, which corresponds 
to the gold eagle, or ten dollars; the hectogram, which corresponds to 
one hundred dollars; and the kilogram, which corresponds to one 
thousand dollars. When we come to the use of the metric system 
for fluids, we use as the unit the milliliter, called the "mil.," or cubic 
centimeter (cc) in place of the gram; a mil., or cubic centimeter, 
representing 1 fluidgram. 

When it is wished to convert grains into their metric equivalent, 
it must be remembered that 0.065, or 65 milligrams, is the equiva- 
lent of 1 grain. Therefore, the following examples may be used : 

3 grains are equal to 3 X 0.065 = 0.195 gram. 
60 grains are equal to 60 X 0.065 = 3.9 grams. 1 

| grain is equal to \ of 0.065 = 0.0162 gram. 
y^-q- grain is equal to T \^ of 0.065 = 0.00065 gram. 
To convert grams into grains, instead of multiplying by 0.065, we 
divide, thus: 

Gram 0.12 is equal to 0.12 4-0.065= 1.8 grains. 

Grams 3.9 are " " 3.9 -v- 0.065 = 60.0 grains. 

Gram 0.06 is " " 0.06 + 0.065 = 0.9 grain. 

Gram 0.0006 is " " 0.0006 -H 0.065 = 0.0092 grain. 

1 Usually considered as 4.0. 



40 



GENERAL THERAPEUTICAL CONSIDERATIONS 



When we wish to convert Apothecaries' drams into grams, we 
multiply the number of drams by 3.9, or, more commonly, though 
less accurately, by 4.0. Thus: 

10 drams X 4.0 = 40 grams, or, more accurately, 
10 drams X 3.9 = 39 grams. 
When grams are to be converted into drams we divide the 
number of grams by 3.9, or approximately 4.0. Thus: 

10 grams -s- 3.9 = 2.56 drams, or, less accurately, 
10 grams -f- 4.0 = 2.5 drams. 
When Apothecary ounces are converted, we multiply by 31.1; or 
if grams are to be converted into ounces, we divide by 31.1. Thus: 
2 ounces X by 31.1 = 62.2 grams. 
40 grams -i- by 31.1 = 1.25 ounces. 
As accurate translation of Apothecaries' weights into the metric 
system leaves a fractional quantity in almost every instance, and as 
the translation of the metric system into Apothecaries' weights does 
likewise, the author has for the sake of presenting even figures, and 
therefore rendering the interchange practicable, considered that the 
Apothecary ounce and the fluidounce are equal to 30 grams or 30 
mils, or cubic centimetres, although a more accurate estimate of the 
ounce is 31.1 and of the fluidounce is 29.57. 

TABLES OF RELATIVE WEIGHTS AND MEASURES IN THE 
METRIC AND APOTHECARIES' SYSTEMS. 

(See Oldberg's Manual of Weights and Measures.) 



Milligrammes in Grains. 



Milligramme. 
0.1 
0.2 
0.3 
0.4 
0.5 
0.6 
0.7 
0.8 
0.9 



Grain. 



"200 
T50" 

l 

T20 
TOO 



Milligrammes. 
1 

1.2 
1.6 

2 

3 
4 

5 
6 

7 



Grain. 



60 

l 
To 



= £> 

= io 



?S 
1 

TO" 

1 
"9 



Milligrammes. 


Graj 


8 


= 


2 
8 


9 


= 


1 
T 


10 


= 


h 


12 


= 


* 


16 


= 


2, 

4 


20 


= 


1 
3 


30 


= 


* 


60 


= 


1 



Centigrammes in Grains. 



Centigrammes 
(or Cent.) 
1 

2 
3 
4 
5 



Grain. 
l 

6 

1 

2 
2 
3^ 



Centigrammes, 
(or Cent.) 

6 

7 

9 

10 
12 



Grains. 
1 

n 
if 

2 



Centigrammes 

(or Cent.) 

18 

25 

50 

75 

100 



Grains. 

3 

4 

8 

12 

16 



DOSAGE 



41 



Grammes in Grains. 



Grammes. 




Grains. 


Grammes. 




Grains. 


Grammes. 




Grains 


0.001 


= 


6*0 


11 


— 


176 


27 


= 


432 


0.010 


= 


1 
6 


12 


= 


192 


28 


= 


448 


0.100 


= 


1 2 


13 


= 


208 


29 


= 


464 


0.250 


= 


4 


14 


= 


224 


30 


= 


480 


0.500 


= 


8 


15 


= 


240 


31 


= 


496 


0.750 


= 


12 


16 


= 


256 


32 


= 


512 


1 


= 


16 


17 


= 


272 


33 


= 


528 


1.50 


= 


24 


18 


= 


288 


34 


= 


544 


2 


= 


32 


19 


= • 


304 


35 


= 


560 


3 


= 


48 


20 


= 


320 


36 


= 


576 


4 


= 


64 


21 


= 


336 


37 


= 


592 


5 


= 


80 


22 


= 


352 


38 


= 


608 


6 


= 


96 


23 


= 


368 


39 


= 


624 


7 


= 


112 


24 


= 


384 


40 


= 


640 


8 


= 


128 


25 


= 


400 


50 


= 


800 


9 


= 


144 


26 


= 


416 


100 


= 


1600 


10 


= 


160 















Mils, or Cubic Centimetres (or Fluidgrammes) in U. S. Apothecaries' 



Mils. 
1 
2 
3 
4 
5 
6 
7 
8 



U.S. 
Fluidrachms. 



= 1 



1* 

11 



= 2 



Fluidrachms. 


/Tils 




u. s 


9 




2} 


10 


= 


2i 


11 


= 


2f 


12 


= 


3 


13 


= 


H 


14 


= 


H 


15 


= 


Si 







U.S. 


vriis. 




Fluidrachms. 


16 


= 


4 


20 


= 


5 


24 


= 


6 


28 


= 


7 


32 


= 


8 


48 


= 


12 


64 


= 


16 



Table of Approximate Percentages. 





Grains per 


Grains per 


Grains per 


To make — 


Fluid ram. 


Fluidounce. 


Fluidpint. 


1 per cent 


0.60 


5. 


73. 


2 • " 








1.15 


9.15 


146. 


3 








1.70 


14. 


219. 


4 








2.30 


18.25 


292. 


5 " 








2.85 


23. 


365. 


6 








3.40 


27.50 


438. 


7 








4. 


32. 


511. 


8 








4.60 


36.50 


584. 


9 








5.15 


41. 


657. 


10 








6. 


46. 


730. 



Based on 57 min. to the drachm, 457 min. to the ounce, and 7300 min. to the pint. 



DOSAGE. 

No one can practice medicine for more than a very brief period 
without becoming convinced that quite as much skill is required on 
the part of the practitioner in determining the dose which is needed 



42 GENERAL THERAPEUTICAL CONSIDERATIONS 

of a given remedy as in deciding upon the remedy itself. It repeatedly 
happens that one physician fails to produce the desired results, 
while another physician immediately gets good effects from the 
same remedy, for no other reason than that he has been more skilful 
in determining the amount which should be administered and the 
frequency of its administration. 

In teaching medical students the dose of remedies it is impossible 
to do more than inform them of the approximate doses. Only 
experience can tell the individual physician the amount which will 
be needed in a given case, and often even those with the largest 
experience have to try several doses before they find the one which 
produces the effects they desire. These facts have much to do 
with the contradictory ideas which exist in different men's minds 
as to the efficiency of a given remedy. One physician states that he 
frequently employs a certain drug and has come to rely upon it as a 
"sheet-anchor" when conditions are desperate; another physician 
replies that he has tried it, and that his results have been as lacking 
in success as the other's have been full of good. This difference of 
opinion does not rest upon any lack of power of observation on the 
part of either man, but upon the judgment of each as to the amount 
of the remedy to be used. If there were more accurate statements 
made as to the doses employed when remedies are suggested by one 
practitioner to another, better results would accrue. 

It is also probably the case that certain physicians consistently 
administer remedies in doses which are too large, or which speedily 
become too large because the drug is one which is persistent in its 
effect, so that after a few doses the patient is not only under the 
influence of the remedy administered on that particular day, but 
also under the influence of doses which have been administered on 
previous days. Then there is the physician who habitually uses too 
small doses, and it may be that in a large number of cases he is a 
better practitioner than he who gives the large ones. Sometimes 
rapidly acting, but fugacious, remedies are given at too long inter- 
vals, or doses of slowly acting, persistent remedies are given too close 
together; and, again, sufficient judgment is not exercised in deter- 
mining exactly what is to be accomplished in a given patient at a 
given time. Thus, in the administration of digitalis it is often wise 
to give one or two rather large doses, and almost always unwise to 
continue them, the proper method being to correct urgent symptoms 
by large doses and then maintain the good effect by smaller ones, 
thereby preventing an excessive digitalis effect, which may be more 
disagreeable or harmful to the patient than the condition for which 
the remedy is administered. 

Another illustration of this is in the administration of alkalies for 
the purpose of combating the acidosis which induces or accompanies 
diabetic coma. It is generally known that sodium carbonate and 



DOSAGE 43 

sodium bicarbonate are to be given by rectal injection or by intra- 
venous infusion in order to, at least in part, restore the fixed bases in 
the blood, but in many instances the quantity of alkali which is 
given is quite insufficient to produce the results desired, because the 
physician does not estimate the degree of the acidosis. It is not 
at all uncommon for these acids to amount to as much as 10 to 20 
grams in the twenty-four hours, and many instances are on record 
in which several times this quantity has appeared in the urine, 
which is an index of the total acidosis of the body. Manifestly 
different doses of alkali have to be used in such cases, and sometimes, 
instead of giving as much as a dram, or 4 grams, it is proper to give 
as much as 3 or 4 ounces of sodium bicarbonate in each twenty- 
four hours. Cases are on record in which as much as 900 grams, 
or 30 ounces, of sodium bicarbonate have been administered without 
neutralizing the urine. In other words, in this condition the alkali 
should be given for effect and not by weight, the principle governing 
its administration being more akin to the employment of an antidote 
in mineral poisoning, or the use of antitoxin in diphtheria, rather 
than to the adjustment of the dose of a drug ordinarily employed for 
the purpose of producing a physiological effect. 

For several reasons there is no absolutely fixed rule which can be 
applied to dosage. In the first place, the individual may not be 
readily affected by drugs, or the disease-process present may so 
antagonize them as to render very large doses necessary. Further, 
the age and sex of a patient have much to do with the regulation of 
the proper amount of a drug to be employed. Finally, that curious 
but common condition of susceptibility to various remedies, that we 
call idiosyncrasy, creeps in as an important factor in the decision as to 
the dose which should be given in each case. 

By far the nearest approach which can be made to absolute 
accuracy in dosage is to use drugs according to the weight of the patient, 
but this method possesses the disadvantage that we cannot always 
weigh our patients, and that the presence of a large amount of fat 
or of dropsy will make an unknown quantity in the calculation as 
to the true weight of the active part of the individual. 

At present we are accustomed to be governed by a list of doses to 
be given to all adults within certain limitations, and which are varied 
sufficiently to permit of great differences in the effects obtained. It 
is in this very factor that the success of many a physician chiefly rests. 
The dose must be varied to fit the case in the same manner that the 
cut of a coat must be varied to fit each individual. 

As already stated, there is not a uniform dose of all preparations of 
the same class, but it will aid the student to bear the following facts 
in mind: With a few exceptions the dose of solid extracts of nearly 
all the powerful drugs is about f to \ grain (0.008-0.016) ; of fluid- 
extracts of nearly all powerful drugs about 2 to 5 minims (0.12-0.3); 



44 



GENERAL THERAPEUTICAL CONSIDERATIONS 



of aromatic oils and liquors containing powerful drugs about 6 to 10 
minims (0.36-0.6); of tinctures of powerful drugs about 5 to 20 
minims (0.3-1.3), except cantharides and iodine, the dose of which 
equals about 2 to 6 minims (0.12-0.36). Of official waters the dose 
is about 1 dram to 1 ounce (4.0-30.0), and of infusions and decoctions 
about 1 dram to 1 ounce (4.0-30.0). 

There are a number of approximate rules in regard to the doses 
which are to be given in treating the diseases of children, the best of 
which is Young's rule. This is as follows: 

Add 12 to the age and divide by the age. Thus, if a child is two 
years old, we have the following formula: 2 + 12 = 14 -f- 2 = 7, or, one- 
seventh of the dose for an adult is the dose for a child of two years 
This rule is not a law, however, for of narcotics children should 
receive less than this (one-half), and of purgatives or laxatives more 
than this (two or three times). 






Fig. 2 



Fig. 3 



Fig. 4 



Figs. 2, 3 and 4. — Graduated medicine glasses. 



When drugs are given hypodermically the dose should be generally 
one-half to one-quarter of that given by the mouth; and if any sus- 
picion of idiosyncrasy exists, the dose should be smaller still at first if 
powerful remedies are to be used. 

By the rectum the dose should be twice the amount given by the 
mouth, unless the drug be very powerful or capable of very rapid 
absorption. 

When ordering liquid medicines in small amounts the prescription 
should always call for minims rather than drops, for the size of a drop 
varies with the particular liquid with which we are dealing and the 
shape of the mouth of the vessel containing it. This is well shown in 
the table following, compiled by Kinsey, and originally published in 
the American Journal of Pharmacy. 

Doses are also ordered in teaspoonful, dessertspoonful, and table- 
spoonful quantities. Sometimes they are given by the wineglassful, 
meaning by this term a sherry-glassful. Roughly estimated, a tea- 



ABSORPTION OF DRUGS 



45 



spoonful equals a fluidram (4.0), a dessertspoonful two nuidrams 
(8.0), and a tablespoonful half a fluidounce (15.5). As spoons and 
wineglasses vary considerably iu capacity, it is always best to use a 
graduated medicine glass, such as is shown in Figs. 2, 3, and 4. 



Dropped from 



CO £1, 

if 



as 



Acetum lobeliae 

Acetum opii 

Acetum sanguinariae . . . 

Acid, acetic. 

Acid, acetic, dilute .... 

Acid, carbolic 

Acid, hydrobromic. . . . 
Acid, hydrochloric. . . . 
Acid, hydrochloric, dil. . 

Acid, nitric 

Acid, nitric, dilute .... 
Acid. nitrohydro?hloric. . 
Acid, nitrohydrochloric. di 

lute 

Acid, phosphoric 

Acid, sulphuric , 

Acid, sulphuric, dilute ... 
Acid, sulphuric, aromatic. . 

Aqua ammoniae j 

Aqua destillata 

Liquor potass, arsen j 

Oleum anisi 

Oleum amygdalae amar. . 

Oleum car'i 

Oleum chenopodii l 

Oleum carophylli ' 

Oleum cinnamomi | 

Oleum crotonis 

Oleum cubebae 

Oleum gaultheriae .... 

Oleum hedeomae 

Oleum lavandulae .... 

Oleum monardae 

Oleum menthae pip. . . . 
Oleum menthae viridis . . 

Oleum myristicse 

Oleum origani 

Oleum pimentse 

Oleum rosmarini 

Oleum sassafras 



102 
82 

94 
82 
57 
60 
70 
82 
63 
87 



54 

160 

57 

97 

45 

64 

58 

76 

102 

108 

94 



95 
105 

82 



91 
102 
92 
83 



74 

54 
43 
152 
47 
94 
41 

"61 

73 I 

77 

84 

75 

75 

73 

62 

80 

93 

83 

78 

76 

73 

81 

83 

83 

86 

88 



64 

65 

92 
101 

99 
110 

70 

96 

62 
124 

81 

92 

62 

62 
172 

60 
144 

54 

61 

77 
112 

75 
133 
129 
133 
112 
104 
120 
136 
130 
133 
125 
132 
132 
128 
133 
133 
133 
142 ! 



Oleum tanaceti . . . 
Oleum terebinthinae . 
Spiritus ammon. ar. . 
Spiritus camphorae . 
Spiritus aether, comp. 
Spiritus aether, nitr. . 
Spiritus menthae pip. 
Syrupus scillae comp. 
Tinctura aconiti . . 
Tinctura asafcetidae . 
Tinctura belladonna? 
Tinctura benzoini co. 
Tinctura cannabis ind 
Tinctura cantharidis 
Tinctura capsici ... 
Tinctura colchici . . 
Tinctura digitalis . . 
Tinctura ferri chlor. 
Tinctura hyoscyami 
Tinctura ignatiae . 
Tinctura iodi . . . 
Tinctura kino . . . 
Tinctura krameriae 
Tinctura lavand. co 
Tinctura lobelise . 
Tinctura myrrhae . 
Tinctura micis vomicae 
Tinctura opii .... 
Tinctura opii camph. 
Tinctura opii deodor. 
Tinctura rhei .... 
Tinctura sanguinariae 
Tinctura stramonii . 
Tinctura tolutani . . 
Tinctura veratri . . . 
Vinum aloes ... 
Vinum colchici rad. . 
Vinum colchici sem. 
Vinum ergota? .... 
Vinum opii .... 



Dropped from 



JS o 

ceo 



110 
103 
108 
98 
120 



106 

120 

102 

94 

98 

124 

118 

116 

86 

114 

108 

114 

112 

112 

116 

117 

97 

110 

100 

112 

98 

94 

109 

98 

110 

100 

120 

108 

71 

92 

86 

148 



87 
102 
85 
81 
81 
120 
97 



100 



95 

105 

92 



S3 



136 
142 
139 
140 
140 
144 
143 
122 
164 
145 
128 
146 
98 
136 
143 
124 
145 
139 
147 
140 
144 
148 
150 
141 
138 
145 
148 
143 
135 
141 
144 
134 
120 
156 
152 
94 
95 
105 
122 
102 



ABSORPTION OF DRUGS. 



Knowledge of the rapidity with which certain drugs are absorbed 
from the various surfaces with which they come in contact is of 
importance in order that we may know when to repeat the dose if the 
first amount does not produce the desired effect. The rapidity of 
absorption depends upon a number of factors. 

Physiological Factors.— If the circulation is active, absorption . is 
rapid; but if it be depressed, absorption is slow. Thus, in a person 
apparently drowned, absorption may not occur at all until the vital 



46 GENERAL THERAPEUTICAL CONSIDERATIONS 

functions are restored, and repeated doses given to the patient while 
unconscious, acting together, may in the end poison him. This is 
often the case in delirium tremens when hypodermic injections of 
morphine are given or when the drug is administered by the mouth. 
In dropsy absorption is peculiarly slow, and a medicine may remain in 
the tissues for days, only to be absorbed with the transudate after 
severe purgation, profuse diuresis, or tapping. In cases of general 
dropsy hypodermic medication is nearly always worse than useless. 

When the stomach or bowel is empty absorption from either is 
rapid, but when they are full it is very slow. In this fact we find 
the reason for the popular idea that a drink of whisky taken when a 
man is hungry makes him drunk, whereas twice that quantity after a 
meal does not do so. 

Drugs in the stomach or bowel have no influence upon the general 
system unless they are irritants. They only act when taken into the 
blood or lymphatics. When the stomach is atonic and its powers of 
absorption impaired, the addition of some irritant or stimulant, such 
as capsicum, will often aid in the absorption of the necessary drug. 

Physical Factors.— The physical characteristics of a drug greatly 
affect the rapidity of its absorption. Thus, the more volatile, diffus- 
ible, and soluble the medicament, the greater the speed with which it 
will enter the circulation. Two solutions belonging to the same group 
of chemical compounds may be utterly different in their action because 
of their physical state, as, for example, the volatile hydrocarbon 
pental, which is absorbed with great rapidity, and the non-volatile 
paraffin, which, although it belongs to the hydrocarbons, is entirely 
without physiological effect. 

Recent studies show that alcoholic solutions of drugs are more 
rapidly absorbed than are watery solutions or those made with 
glycerin or milk. 



DURATION OF ACTION OF DRUGS. 

The duration of the action of drugs depends partly upon their 
rapidity of absorption, but chiefly upon the rapidity or slowness of 
their decomposition or destruction in the body and their elimination 
from it. Thus, volatile substances, such as ether, chloroform, and 
nitrite of amyl, act only for a short time and are quickly eliminated; 
whereas bromide of potassium and digitalis continue active during 
many hours, and are slowly eliminated, as in the case of the former, 
or oxidized, as in that of the latter. Again, if curare is given hypo- 
dermically it will cause paralysis, but if taken by the stomach in 
moderate amount it will be eliminated by the kidneys as rapidly as it 
is absorbed, and produce no effects if these organs are active. 

So, too, if a. patient's kidneys are healthy, very large doses of the 



COMBINATION OF DRUGS FOR JOINT EFFECT 47 

potassium salts are harmless; but if he suffers from nephritis so 
that the potash is not rapidly eliminated they become dangerous 
depressants. 

From studying the duration of the action of a drug we learn how 
often to order a dose. Thus, digitalis may be given once, twice, or 
thrice a day, but carbonate of ammonium must be given every two 
or three hours to maintain its effects. 

When the physician is not careful in the use of a potent drug which 
is eliminated slowly, it may suddenly develop so severe an effect as to 
cause alarm, owing to its accumulation in the body. This is called 
" cumulative action." 



COMBINATION OF DRUGS FOR JOINT EFFECT. 

The study of the physiological action of drugs has aided very 
greatly in improving our therapeutic measures. Thus, we now know 
that chloral is a heart-depressant and cannot be used in very full 
doses, or pushed to produce sleep in persistent insomnia, without 
grave danger; whereas morphine, which also produces sleep but does 
not depress the heart, but does depress the respiration, can be com- 
bined with it, and the two acting together, each in small dose, produce 
a heavy sleep, although so little chloral is present that the heart is 
safe, and so small an amount of morphine is used that the respiration 
does not suffer. 

Another example of this is found in certain purgative pills in which 
the purgative agent is assisted by belladonna and nux vomica, the 
first of which relaxes muscular spasm, while the second acts as a tonic 
to the alimentary tract, the drugs combining to accomplish one result. 

Skill in the combination of drugs, not only for increased physiolo- 
gical effect, but also for the purpose of making their administration 
pleasant to the taste, has much more to do with professional success 
than is generally supposed. This is particularly so in regard to chil- 
dren, for parents dislike forcing their children to take doses which 
they themselves regard as unpleasant, and they are every ready to 
believe that as long as a medicine tastes good it is better than one 
which tastes otherwise. 

The medical practitioner who prescribes never so wisely and appro- 
priately for a patient, but who is utterly regardless as to his combi- 
nations of drugs so far as taste is concerned, will sooner or later see a 
more ignorant man take from him that practice which his greater 
widsom entitles him to, but which is driven from him by his own 
errors in this matter. 

While in some cases there is no alternative but to give an unpleas- 
ant dose, in others a little thought and care will often avoid offending 
the taste of the patient. 



48 GENERAL THERAPEUTICAL CONSIDERATIONS 

STRENGTH AND RELIABILITY OF DRUGS. 

If a census could be made of those who die annually from the use 
of drugs which are impure or useless from weakness, the writer 
believes that a most alarming array of figures would be presented. 
For many years this was unavoidable to a great degree, either because 
our knowledge of the active principles of drugs and the methods of 
isolating them was deficient, or because the time consumed in their 
transportation by sailing vessels or on the backs of natives from the 
countries in which the natural products yielding the drugs were 
obtained, permitted deterioration to take place. At present these 
difficulties have been largely overcome. The trained pharmacist is 
taught how to make an assay for active principles in most of the 
valuable alkaloidal drugs, and every physician should make careful 
investigation into the quality of all preparations which he employs. 
As an illustration of this matter the following facts are of interest. 
An intimate friend of the writer bought from five of the leading 
druggists of Philadelphia six ounces of tincture of nux vomica which 
were stated to have been made according to the directions of the 
United States Pharmacopoeia. That made by perhaps the leading 
druggist of the five contained twice as much strychnine and brucine 
as it should, and had twice as much solid residue; or, in other words, 
a physician prescribing this tincture in full dose would probably 
have poisoned his patient and reported the case as one of unusual 
susceptibility to drugs! On the other hand, the author has seen 
a tincture of nux vomica which contained only a trace of alkaloid, 
but had much inert solid residue. In neither instance was the drug- 
gist dishonest intentionally, but one had used a crude drug which was 
unusually rich in alkaloids, while the other had purchased nux vomica 
beans which, by reason of immaturity, bad surroundings, or exposure 
to weather, were very poor in active principles. Such an uncertainty 
as to the strength of his particular product is now prevented by the 
directions of the U. S. Pharmacopoeia, but the illustration as to 
many other drugs still holds good. All these disadvantages may 
be avoided if physicians will insist that the druggists who dispense 
the drugs they order shall either themselves prepare assayed pro- 
ducts, or purchase such products from any one of the large manu- 
facturing chemists who put assayed goods on the market. When this 
is impossible, the physician should employ the alkaloids in pill form, 
or, if solutions are desirable, the alkaloid may be added to alcohol or 
water and given by drops, as is the case with any ordinary tincture. 
Digitalis, veratrum viride, and ergot are practically the only drugs of 
importance of which an assay cannot be made; in the first and third 
the action of the drug does not depend upon a single active principle, 
but upon a number difficult of assay, and in the second the relative 
proportions of jervine and protoveratrine cannot well be estimated. 



IDIOSYNCRASY • 49 

All drugs should be physiologically tested when their chemical assay is 
impossible. Not long since several thousand pounds of ergot were 
found to be worthless on being tested physiologically by one firm; 
but it was put upon the market nevertheless, for certain manufactur- 
ers do not employ this method of examination. Constant uncertainty 
as to the strength of a drug is a dangerous element when dealing with 
patients who are desperately ill; and in many cases failure and dis- 
couragement will both be avoided if the physician will see to it that 
the drugs which he administers are capable of doing what he requires 
of them. A poor drug to the physician is worse than a poor knife to 
the surgeon; for the failure in the one case is unknown, while in the 
other it can be carefully watched and guarded. 

IDIOSYNCRASY. 

This is one of the most interesting features of the study of the action 
of drugs. It is a frequent cause of disappointment to both patient 
and physician, and an equally frequent cause of excessive action from 
what the medical attendant has thought to be a moderate dose. No 
rule can be laid down for the discovery of idiosyncrasy in a given case, 
except that females, particularly of the hysterical type, are more sub- 
ject to it than are males, although certain men often present marked 
evidences of this tendency. No better illustration of idiosyncrasy can 
be adduced than the case which here follows, nor than that of a friend 
of the author who cannot eat a strawberry without suffering from a 
violent attack of hives. 

The first case is that of a woman of thirty years, suffering from 
a severe headache, who received an eighth of a grain of the hydro- 
chloride of pilocarpine, hypodermically, every twenty minutes, until 
nearly three-fourths of a grain was taken, without any evidence of 
its action either in salivary flow or sweat. But the tolerance of 
drugs did not stop here. Twenty drops of tincture of cannabis 
every four hours failing to relieve the pain, half-grain pills of the 
solid extract were ordered, two of which commonly affect a grown 
man most markedly. The extract had been proved to be active in 
other patients. In order to avoid any failure in absorption the pills 
were each cut in half before they were given, and forthwith adminis- 
tered, one every three hours, without any effect after ten had been 
taken. Twenty more of the pills from the same manufacturers, but 
from a different retailer, were now given, one every hour with the 
exception of a few irregularities in administration during the night, 
the entire twenty being swallowed between four o'clock one after- 
noon and two o'clock the next afternoon. The thirty pills (fifteen 
grains) were taken in less than forty-eight hours without producing 
a single physiological sign of the slightest character. That the doses 
were reallv swallowed would seem to be undoubted, for their admin- 



50 GENERAL THERAPEUTICAL CONSIDERATIONS 

istration was carried out by a trained attendant, and their black color 
forbade their expulsion from the mouth on the bed without attracting 
attention. The hypodermic injections were given by the author, and, 
as the solution was used as fast as it was made, the patient must 
certainly have received all of the pilocarpine. As there was daily an 
afternoon rise of temperature amounting to several degrees, quinine 
bisulphate was ordered in the dose of fifteen grains, to be given after 
six powders of one-sixth of a grain of calomel had been taken; this 
not only failed to control the fever, but also produced no buzzing in 
the ears. The writer was now inclined to consider all the symptoms 
as hysterical, even including the evening rise of temperature. 
Twenty-four hours after the last dose of cannabis the attendant gave 
the patient, without orders, no less than sixty grains of antipyrine in 
sixteen hours without any physiological symptoms, and, under orders, 
she took from forty to fifty grains of bisulphate of quinine every day 
for three days without any signs of cinchonism. 

Wide experience has taught us, however, that several conditions 
act fairly constantly in regard to some idiosyncrasies. Certain dis- 
eased conditions— such as peritonitis or pain— allow large doses of 
opium to be given, and in lead poisoning and paralysis patients may 
take enormous doses of active purgatives without moving the bowels. 

The climate in which the patient lives, or has been accustomed to 
live, renders him more or less susceptible to certain remedies. Thus 
the East Indian runs amuck after eating hasheesh or cannabis, or the 
Chinaman goes into a delightful dreamland from smoking opium, 
whereas the Anglo-Saxon experiences no such agreeable sensation, 
as a general rule. Southerners generally require larger doses of 
purgatives than Northerners, often because the liver is not so active. 

The temperament of an individual is also a highly important matter 
to be considered. It is a notorious fact that phlegmatic dark-skinned 
individuals usually yield to drugs less readily than blondes and 
nervous persons, more especially in respect to the drugs which act on 
the nervous system. Nervous light-haired women stand belladonna 
very badly as a general rule, while children will take large doses often 
without discomfort. Opium is usually badly borne by children. 

Habit is another important factor governing idiosyncrasy. We all 
know how rapidly one becomes accustomed to tobacco and how 
morphine habitues take enormous amounts of their favorite drug 
without effect. 

INDICATIONS, CONTRAINDICATIONS AND DEFINITIONS. 

The indication for a drug is any symptom or condition, or series 
of symptoms or conditions, which we know the drug will relieve 
without causing at the same time an evil effect to be felt by other 
parts of the body. A contraindication is any coexisting state or 



INDICATIONS, CONTRAINDICATIONS AND DEFINITIONS 51 

tendency which will be made so much worse by the drug as to forbid 
its use. Thus, one might be tempted to give quinine in meningitis 
for the fever, yet this would be bad therapeutics, since quinine is 
contraindicated because it will increase the meningeal congestion. 

Abortifacients form a class of drugs,, which, as such, ought never to 
be employed. If pregnancy is to be interfered with, the interruption 
should be produced by instrumental means, and then only after con- 
sultation with another practitioner to get his views and protect one's 
self from possible legal difficulties. 

Alteratives are generally indicated where abnormal cell-growth is 
active to excess, but contraindicated where tissue break-down is 
present, or when there exists a tendency thereto. 

Anesthetics are used to 'abolish sensation. They are either local or 
general. Many of the local anesthetics produce loss of sensation 
through benumbing the parts by the cold they produce. Cocaine 
is an example of a local anesthetic which causes anesthesia by a direct 
paralyzant action on the peripheral sensory nerves. The general 
anesthetics are taken by inhalation and act upon the higher centers 
in the brain. 

Anaphrodisiacs are used to diminish sexual desire. 
Aphrodisiacs are used to increase sexual desire and power. 
Antacids are employed in cases in which, as a result of morbid pro- 
cesses, lactic and butyric acids, or even hydrochloric acid, are found 
in abnormal quantities in the stomach. 
Anthelmintics are used for the purpose of removing intestinal worms. 
Antiarthritics is the name given those drugs which are employed 
for the purpose of relieving inflammations occurring in joints, whether 
these be in an acute or chronic condition of disease. 

Antihydrotics are used to prevent excessive sweating, either local 
or general. Camphoric acid is probably the best general antihydrotic. 
Antiperiodics is a term applied to drugs or remedies employed for 
the prevention or cure of malarial " poisoning. They are so named 
because they tend to diminish or arrest the periodicity of the attacks, 
which periodicity is a characteristic of such diseases. 

Antiphlogistics are employed to prevent the progress of inflamma- 
tory processes. They are nearly all contraindicated in the presence 
of tissues possessing impaired vitality through previous conditions of 
disease. 

Astringents are employed for the purpose of contracting or con- 
stringing tissues. They act either by coagulation of albumin, by 
precipitating albumin, or by making the tissues more dense by con- 
centration. Theoretically, all astringents should be non-irritating, 
but practically they possess irritant properties, and are, in conse- 
quence, contraindicated in the presence of very acute inflammations 
as a rule. Three of the mineral astringents, however, possess marked 
sedative properties in addition to their astringent power, and can 



52 GENERAL THERAPEUTICAL CONSIDERATIONS 

therefore be used freely in acute inflammation when locally applied. 
They are nitrate of silver, subacetate or acetate of lead, and the 
subcarbonate or subnitrate of bismuth. 

Bitters are designed to increase the activity of the mucous mem- 
brane of the gastro-intestinal canal by increasing its tone. They 
may be divided into simple bitters and complex bitters. The first 
depend upon their bitterness solely for their activity; the second class 
is well represented by quinine and strychnine, both of which are 
exceedingly bitter, but, in addition to their local effect on the gastro- 
intestinal mucous membrane, act as stimulants to other portions of the 
organism. A good example of a simple bitter is columbo. Many 
bitters contains so much tannic acid that they are not generally useful, 
and for this reason very few can be used with preparations of iron, 
since a tannate of iron would be formed. 

Cardiac sedatives decrease the force of the heart, and, as a class, the 
amount of blood expelled at each beat of the ventricles. They are 
indicated in arterial excitement and contraindicated in arterial 
depression. 

Cardiac stimulants increase the force of the heart, thereby increas- 
ing the quantity of blood expelled from the ventricles. Their effect 
may be accomplished by an increase in the rapidity of the beats or 
by a greater output of blood at each contraction, the diastole being 
sufficiently prolonged to admit of the ventricles being well filled. 
They are contraindicated in the presence of arterial excitement, and 
indicated in arterial depression. 

Carminatives are given for the purpose of expelling flatus, particu- 
larly if there is reason to believe that the "wind" has accumulated 
because of intestinal torpidity. Many of the carminatives are neces- 
sarily possessed of irritant properties, and are therefore contraindi- 
cated in the presence of flatulence due to intestinal atony arising from 
inflammation. The best carminative is spiritus etheris. 

Cathartics.— These are drugs employed when a positive and decided 
action of the bowels is desired. They occupy a position between the 
purges and the drastics. (See Purges and Drastics.) 

Cholagogues are used to exert a stimulant influence upon the flow 
of bile. Nitrohydrochloric acid and mercury bichloride are perhaps 
the best types of pure cholagogues, while podophyllum, blue mass, 
and calomel represent the class of cholagogues which increase intes- 
tinal peristalsis in addition to stimulating the flow of bile. Chola- 
gogues are, as a rule, contra indicated in the presence of acute 
inflammation of the gall-bladder or liver. 

Counterirritants are used to produce irritation at a spot distant 
from a painful or inflamed area, in order to relieve the diseased parts 
by reflex action exerted through the nervous system upon the painful 
nerve or disordered capillary network. 

Demulcents are used to protect from irritation any exposed parts 
of the body. 



INDICATIONS, CONTRAINDICATIONS AND DEFINITIONS 53 

Diaphoretics produce an increased secretion from the sweat-glands. 
They may be considered as internal and external. The internal are 
represented by pilocarpine, which stimulates the sweat-glands them- 
selves; the external are represented by the Turkish and Russian 
baths which, by increasing bodily heat and dilating bloodvessels, 
cause a profuse sweat. 

Diuretics are used to increase the flow of urine from the kidneys. 
They act by stimulating the renal epithelium to greater activity, 
thereby increasing the excretion of both the watery and solid con- 
stituents of the urine; or they simply increase the watery constituents 
by increased blood-pressure in the kidney. 

It is to be remembered that the vegetable salts of potassium and 
the lithium salts increase the solids in the urine, not by stimulating 
the secreting epithelium of the kidney, but by uniting with insoluble 
material in the system, forming soluble compounds which are then 
readily eliminated. (See Eliminators.) They are indicated in con- 
ditions of renal inactivity due either to functional or organic causes. 
Irritating diuretics, such as cantharides, for example, are contra indi- 
cated in acute nephritis. Such a diuretic is only to be used where 
the kidneys are inactive through atony or prolonged chronic or 
subacute disease. 

Eliminators are drugs which, by forming soluble compounds with 
insoluble substances in the body, render them capable of being 
excreted by the excretory organs, such as the skin, kidneys and 
bowels. 

Emetics are used to produce vomiting. They act centrally when, 
as is the case with apomorphine, they stimulate the vomiting center; 
peripherally when they irritate the walls of the stomach. They are 
indicated when w r e wish to unload the stomach of undesirable mater- 
ials, or when we desire to cause an increased flow of bile from the 
gall-bladder, which is accomplished by the pressure exerted upon 
this viscus when the abdominal walls and diaphragm contract in 
retching. 

When the ducts are mechanically obstructed by a gallstone emetics 
are dangerous, as they may cause rupture of the gall-bladder. 

Sometimes we are able by the use of emetics to rid the lungs and 
stomach of mucus in bronchitis or gastric catarrh. 

The contra indications to emetics are cerebral congestion or men- 
ingitis, gastritis, gastric ulcer, advanced pregnancy and hernia. 

Emmenagogues are used to produce or increase the menstrual flow. 

They are of two classes— direct and indirect. The direct are 
many of them irritants, and are seldom of much value with the 
exception of corpus luteum; the indirect are used to overcome the 
morbid condition underlying the menstrual disorder, and are therefore 
more rational. Thus iron and arsenic may be used with beneficial 
result in amenorrhea due to anemia. 



54 GENERAL THERAPEUTICAL CONSIDERATIONS 

Expectorants are employed when it is desirable to promote secre- 
tion or to get rid of secretion in the bronchial tubes. Thus, in the 
early stages of an acute bronchitis the mucous membrane is hyperemic 
and swollen, but dry and irritable. Ipecac and citrate of potassium 
form at this time a sedative expectorant mixture, which, while 
allaying irritation, promotes secretion and so relieves the engorged 
area. On the other hand, after the acute stage is passed, there may 
be so much atony of the mucous glands that the secretion is either 
too scanty or too viscid to be coughed up. Stimulant expectorants, 
such as chloride of ammonium, eucalyptus and terebene are now to 
be employed. These latter drugs are contraindicated in the acute 
inflammatory stage of the disease, as they would simply stimulate 
the mucous membrane to greater irritation. 

Hypnotics are used to produce sleep. They may be divided into 
those which produce sleep and relieve pain, and those which have no 
analgesic power. The latter are therefore not to be employed in 
sleeplessness due to pain, and the former are contraindicated when 
pain is absent. Thus, barbital sodium produces sleep, if it be ordi- 
nary functional insomnia; but if the sleeplessness is due to pain, 
opium is the drug to be employed. Barbital sodium, in ordinary 
doses, is the purest hypnotic that we have. 

Mydriatics produce dilatation of the pupil, or mydriasis. Condi- 
tions of the eye associated with increased intraocular tension are 
contraindications to mydriatics, as a rule. 

Myotics cause contraction of the pupil or myosis. They are best 
represented by eserine. 

Nervous sedatives are indicated and contraindicated in a reverse 
manner to nervous stimulants. 

Nervous stimulants are contraindicated in nervous excitement, and 
indicated in nervous depression. 

Oxy toxics increase the expulsive power of the uterine muscle. 

Revulsives are used to produce increased activity of the general 
system or parts thereof through reflex influences— that is, they cause 
a determination of blood to one part, thereby relieving an engorged 
area. Thus, in cerebral congestion or effusion a vigorous purgative 
or cathartic may give relief by exercising a derivative effect. Revul- 
sives are closely allied to counterirritants. 

Roborants are devoted to the repair and building up of tissues in 
the body, and comprise both food and drugs. Roborant treatment 
also includes hygienic surroundings, fresh air, light and healthful 
employment. 

Tonics are used to increase vital activity. They are indicated in 
local or general systemic depression and contraindicated in cases of 
inflammation or excitation with excessive functional activity. (See 
Bitters.) 



CLASSIFICATION OF DRUGS 



55 



Vasomotor depressants decrease arterial pressure by an action on 
the vasomotor nervous system rather than by an action on the 
heart. They act by relaxing the bloodvessels. 

Vasomotor stimulants increase arterial pressure by an action on the 
vasomotor system, thereby producing contraction of the bloodvessels. 



CLASSIFICATION OF DRUGS. 

In order that the student may gain a definite idea as to the various 
actions of different remedies the following list of drugs is appended, 
which is of necessity somewhat arbitrary and is not intended to 
be exhaustive, for many remedies might be placed in several classes. 
The endeavor has been made to place the best or most powerful 
drug of each class first in the list. It is to be remembered that a 
strict physiological classification is impossible. 



I. Alteratives. 




Those used against the tape-worm 


1. Mercury. 




are — 


2. The iodides of potassium and 
sodium. 


1. Pelletierine. 


3. Iodine. 




2. Aspiditim. 


4. Iodoform. 

5. Iodol. 




3. Pepo. 

4. Pomegranate. 


8. Arsenic. 

7. Cod-liver oil. 

8. Colchicum. 

9. Ichthyol. 




5. Brayera. 

6. Kamala. 

7. Turpentine. 

8. Chloroform. 


10. Taraxacum. 






11. Mezereum. 




Those used against the seat worm, oi 


II. Anaesthetics. 




Oxyuris vermicularis, are — 


1. Ether. 




1. Quassia. 


2. Nitrous oxide gas. 




2. Turpentine. 


3. Chloroform. 




3. Tannic acid. 


4. Cocaine. 




4. Sodium chloride. 


5. Eucaine. 




5. Vinegar. 


6. Bromide of ethyl. 






7. Chloride of ethyl and of methyl. 

8. Pental. 

9. Bromoform, 


V. Antiseptics. (See also Disinfect, 
ants. ) 


10. Phenol. 




1. Corrosive sublimate in weak 


11. Antipyrine. 




solutions. 


12. Menthol. 




2. Phenol (carbolic acid.) 


III. Antacids. 




3. Peroxide of hydrogen. 

4. Creolin. 


1. Ammonia. 




5. Lysol. 


2. Sodium and its salts. 




6. Boric acid. 


3. Liquor potassii hydrox: 




7. Permanganate of potassium. 


4. Magnesia. 




8. Salicylic acid. 


5. Lime. 




9. Sulphate of iron. 


TV. ANTHELMINTICS. 






Those that are used against the 


round- 


VI. Antipemodics or Antimalarials 


worm are — 




1. Cinchona. 


1. Santonica. 




2. Eucalyptus. 


2. Spigelia. 




3. Warburg's tincture, 


3. Chenopodium. 




4. Arsenic. 


4. Azedarach. 




5. Methylthionine hydrochloride 
(methylene blue.) 



56 



GENERAL THERAPEUTICAL CONSIDERATIONS 



VII. Antipyretics. 

1. Antipyrine. 

2. Acetanilide 

3. Acetphenetidin (phenacetin.) 

4. Guaiacol. 

5. Phenocoll. 

6. Quinine. 

7. Salicylic acid. 

8. Phenol (carbolic acid). 

VIII. Antispasmodics. 

1. Amyl nitrite. 

2. Hydrated chloral. 

3. Bromides. 

4. Opium. 

5. Belladonna. 

6. Camphor. 

7. Hoffmann's anodyne. 

8. Asafoetida. 

9. Musk. 

10. Valerian. 

11. Monobromated camphor. 

12. Amber. 

13. Cimicifuga. 

14. Hops. 

IX. Astringents. 
Vegetable : 

1. Tannic acid. 

2. Haematoxylon. 

3. Kino. 

4. Gambir. 

5. Rhatany or krameria. 

6. Rhus glabra. 

7. Geranium. 

8. White oak. 

9. Black oak. 

10. Gallic acid. 

11. Rosa centifolia. 

12. Rosa gallica. 

All of these depend chiefly upon tan- 
nic acid for their active principle. 
Mineral : 

1. Sulphuric acid. 

2. Alum. 

3. Lead. 

4. Nitrate of silver. 

5. Nitric acid. 

6. Sulphate of copper. 

7. Bismuth. 

8. Sulphate of zinc. 

X- Cardiac Sedatives. 

1. Aconite. 

2. Veratrum. 

3. Antimony: 

4. Hydrocyanic acid. 

5. Veratrine. 

XI. Cardiac Stimulants. 

1. Digitalis. 

2. Strophanthus. 

3. Ammonia. 

4. Ether. 

5. Alcohol. 

6. Caffeine. 

7. Nux vomica. 

8. Ignatia. 

9. Adonis vernalis. 

10. Convallaria majalis. 

11. Sparteine. 

12. Amyl nitrite (momentarily). 

13. Opium. 



XII. Counter-irritants. 

Those counter-irritants that blister 
are called epispastics. They are — 

1. Cantharides. 

2. Thapsia. 

3. Ammonia or chloroform when 

under a watch-glass. 

Those that redden or produce local 
hyperaemia of the skin are — 

1. Mustard. 

2. Capsicum. 

3. Turpentine. 

4. Ammonia. 

5. Chloroform. 

6. Burgundy pitch. 

7. Canada pitch. 

8. Most of the spices. 

Under the name of Escharotics are 
grouped a number of substances 
capable of acting as destructive 
agents upon the soft tissues of the 
body. They are— 

1. Chromium trioxide (chromic 

acid ) . 

2. Nitric acid. 

3. Sulphuric acid. 

4. Nitrate of mercury (solution). 

5. Bromine. 

6. Potassium hydroxide. 

7. Sodium hydroxide. 

8. Burnt alum. 

9. Arsenic trioxide. 

10. Chloride of zinc. 

11. Vienna paste. 

12. Canquoin's paste. 



XIII. Diaphoretics. 

The only ones that we know as direct 
stimulants to the glands are — 

1. Pilocarpus or jaborandi. 

2. Warburg's tincture. 

The others are — 

3. Hot dry and hot moist baths. 

4. Dover's powder. 

5. Alcohol (particularly when 

hot). 

6. Nitrous ether. 



XIV. DlGESTANTS. 

1. Pancreatin. 

2. Pepsin. 

3. Hydrochloric acid. 

4. Diastase. 

5. Papain. 



XV. Disinfectants. 

1. Corrosive sublimate. 

2. Chlorine or chlorinated lime. 

3. Formaldehyde. 

4. Phenol. 

5. Chloride of zinc. 



CLASSIFICATION OF DRUGS 



57 



XVI. Diuretics. 

Those that increase both the solids 
and liquid constituents are proba- 
bly— 

1. Caffeine. 

2. Squill. 

3. Cantharides. 

4. Buchu. 

5. Vegetable salts of potassium. 

6. Lithium. 

7. Juniper. 

8. Turpentine. 

9. Uva ursi. 

10. Chimaphila. 

11. Cubebs. 

12. Pareira brava. 

Those which increase the watery por- 
tion of the urine without increas- 
ing the solids proportionately are — 

1. Digitalis. 

2. Strophanthus. 

3. Apocynum. 

4. The Nitrites. 

XVII. Eliminatives. 

1. The iodides. 

2. The salicylates. 

3. The vegetable salts of potas- 

sium and the purgatives. 

4. The lithium salts. 

5. Jaborandi. 

6. Colchicum (probably). 

XVIII. Emmenagogues. 

The direct emmenagogues are — 

1. Apiol. 

2. Dioxide of manganese. 

3. Permanganate of potassium. 

4. Cantharides. 

5. Aloes. 

6. Myrrh. 

7. Rue. 

8. Savine. 

9. Tansy. 

10. Pennyroyal. 

11. Guaiac. 

The indirect are — 

1. Iron. 

2. Arsenic. 

3. Copper. 

4. Tonics in general. 

XIX. Emetics. 

The direct are represented by — 

1. Apomorphine. 

2. Ipecac (which is both centric 

and peripheral). 

3. Tartar emetic (which is both 

centric and peripheral). 

The peripheral are— 

1. Sulphate of zinc. 

2. Mustard. 

3. Alum. 

4. Sulphate of copper. 

5. Turpeth mineral. 

XX. Expectorants. 
Sedatives : 

1. Citrate or acetate of potassium. 

2. Ipecac. 

3. Antimony. 

4. Lobelia. 



Those which act as stimulating ex- 
pectorants are — 

1. Ammonium chloride. 

2. Apomorphine. 

3. Creosote. 

4. Eucalyptus. 

5. Tar. 

6. Terebene. 

7. Terpine hydrate. 

8. Oil of sandal-wood. 

9. Sulphur. 

10. Grindelia robusta. 

11. Garlic. 

12. Squill. 

Besides these we have nux vomica, 
which increases expectoration by stim- 
ulating the nervous system to coughing, 
and thus expels the mucus. Opium and 
the bromides depress the nervous sys- 
tem and allay cough, and so decrease 
expectoration. 

XXI. Hypnotics. ■ 

1. Barbital sodium. 

2. Barbital (veronal). 

3. Sulphpnethylmethane (trional). 

4. Sulphonmethane (sulphonal). 

5. Chloral hydrate. 

6. Bromides of potassmm, sodium, 

etc. 

7. Opium. 

8. Tetronal. 

9. Paraldehyde. 

10. Chloralose. 

11. Chloralformamide ( chlorala- 

mide). 

12. Hypnal. 

13. Hyoscine (in mania). 

14. Duboisine (in mania). 

15. Cannabis (in large dose). 

XXII. Nervous Sedatives. 

1. Hydrated chloral. 

2. Opium (in full doses). 

3. The bromides and hydrobromic 

acid. 

4. Chloroform. 

5. Amyl nitrite. 

6. Nitrites of potassium and sodi- 

um and nitroglycerin. 

7. Ether. 

8. Bromide of ethyl. 

9. Nitrous oxide. 

10. Bromoform. 

11. Belladonna. 

12. Antipyrine. 

13. Acetanilide. 

14. Acetphenetidin (phenacetin). 

15. Calabar bean. 

16. Hydrocyanic acid. 

17. Lobelia. 

18. Conium. 

19. Cannabis. 

20. Sulphonmethane (sulphonal). 

21. Croton chloral. 

22. Paraldehyde. 

23. Camphor. 

24. Monobromated camphor. 

25. Asafoetida. 

26. Amber. 

27. Hoffmann's anodyne. 

28. Cimicifuga. 



58 



GENERAL THERAPEUTICAL CONSIDERATIONS 



29. Musk. 

30. Valerian. 

31. Humulus. 

32. Castor. 

33. Hypnal. 

XXIII. Nervous Stimulants. 

1. Nux vomica. 

2. Ignatia. 

3. Coca. 

4. Kola. 

5. Caffeine. 

XXIV. Oxytocics. 

1. Pituitrin. 

2. Ergot. 

3. Cotton-root. 

4. Ustilago maydis. 
And indirect when in labor. 

1. Quinine. 

2. Kola. 

XXV. Purgatives. 
Laxatives: 

1. Rhamnus purshiana (cascara, 

sagrada). 
2 Aloes. 

3. Phenolphthalin. 

4. Sulphur. 

5. Rhubarb. 

6. Frangula. 

7. Cassia fistula. 

8. Euonymus. 

9. Magnesium oxide (magnesia). 

10. Manna. 

11. Fruits. 

Cathartics (mineral) : 

1. Magnesium sulphate. 

2. Magnesium citrate. 

3. Sodium phosphate. 

4. Potassium and sodium tartrate. 

5. Sodium sulphate. 

6. Mercury. 

Cathartics (vegetable) : 

1. Castor oil. 

2. Senna. 

3. Podophyllin. 



Cathartics (hydragoguc) : 

1. Elaterium. 

2. Jalap. 

3. Colocynth. 

4. Croton oil. 

5. Gamboge. 

6. Scammony. 

7. The saline purgatives, if con- 

centrated solutions are used. 

XXVI. Tonics. 

1. Cinchona. 

2. Nux vomica. 

3. Calumba. 

4. Arsenic. 

5. Phosphorus. 

6. Mercury (in minute doses). 

7. Copper. 

8. Iron. 

9. Hydrochloric acid. 

10. Nitro-hydrochloric acid. 

11. Nitric acid. 

12. Phosphoric acid. 

13. Condurango. 

14. The vegetable bitters in gen- 

eral. 

XXVII. Vasomotor Depressants. 

1. Amyl nitrite. 

2. Nitroglycerin and other ni- 

trites. 

3. Veratrum. 

4. Antimony. 

5. Aconite. 

6. Alcohol (in excessive doses). 

7. Jaborandi. 

XXVIII. Vasomotor Stimulants. 

1. Belladonna. 

2. Pituitrin. 

3. Suprarenal gland. 

4. Digitalis. 

5. Nux vomica. 

6. Ergot. 

7. Caffeine. 

8. Convallaria. 



INCOMPATIBILITY. 

One of the uses of a knowledge of chemistry and pharmacy to a 
practitioner of medicine is the avoidance of what is known as an 
"incompatibility/' or the placing in a prescription of two or more 
substances which will undergo chemical interchanges, decompositions, 
precipitations, or cause the formation of explosive mixtures. It is 
impossible in this book to detail all the incompatibilities, and only 
the most dangerous and common possibilities of error can be 
considered : 

1st. An acid should never be combined with an alkali. 

2d. A strong acid should not be added in any quantity to a tincture. 
The following prescription is an illustration of this: 

1$ — Potassii iodidi 5ij- 

Acidi nitro-hydrochlorici f 3.1 • 

Tincturae cinchonae composite q. s. f"5iij. — M. 

S. — Use as directed: a teaspoonful. 



INCOMPA TIBILI TY 59 

In this ridiculous mixture the acid is incompatible with the iodide 
of potassium, forming a chloride and setting free iodine, and would 
also change part of the alcohol in the tincture into an ether. 

3d. Alkalies and neutral bases should not be combined with the 
alkaloidal salts. 

1$ — Strychninse sulphatis gr. j 

Potassii iodidi 3ij 

Syrupi sarsaparillae compositi f§iij- — M. 

S. — Teaspoonful t. i. d. 

In this prescription the strychnine would be precipitated by the — 
potassium salt, and the patient would get nearly all the strychnine 
in the last dose. 

4th. Potassium chlorate should not be ordered to be rubbed up 
with tannic acid nor any other organic substance capable of oxida- 
tion, as it will explode. Permanganate of potassium is subject to 
the same rule. 

5th. Chlorate of potassium and ammonium chloride when mixed 
together may ignite. 

6th. Iron is incompatible with tannic acid, as it forms a tannate 
of iron, or ink. As most of the vegetable astringents contain tannic 
acid, they should none of them be used with iron except columbo 
quassia. 

7th. Tannic acid should never be added to solutions of alkaloids. 

8th. Gum arabic is not to be added to solutions of iron, lead 
or the mineral acids. 

9th. Alcoholic solutions of camphor and similar resinous substances 
are incompatible with water. 

10th. Most fluidextracts are incompatible with water, as the 
addition of water will precipitate them. 

11th. All salts not acid but alkaline in reaction are decomposed 
by acids. 

12th. All salts which are acid are decomposed by alkalies. 

13th. All vegetable acid salts are altered by mineral acids and 
are decomposed by alkalies. 

14th. Iodine and the iodides should not be given with alkaloids. 

15th. Corrosive sublimate, the salts of lead, iodide of potassium 
and nitrate of silver should always be prescribed alone,, except in 
the following instances : 

(a) Corrosive sublimate may be given with potassium iodide, 
since it will throw down a precipitate which redissolves and forms 
a double salt. 

(b) Nitrate of silver may be used with extract of opium or hyo- 
scyamus. 

16th. Syrup of squills should not be given with the carbonate of 
ammonium, as it contains acetic acid. Chloride of ammonium is 
not incompatible with it. 



60 GENERAL THERAPEUTICAL CONSIDERATIONS 

17th. Cherry-laurel water should not be prescribed with morphine, 
as it may form the poisonous cyanide of morphine. 

18. Chloral and cyanide of potassium should never be placed in 
the same prescription, as they will decompose each other, setting free 
hydrocyanic acid. 

19th. Cocaine and borax when added together form an insoluble 
borate of cocaine. Boric acid and cocaine do not result in this 
formation. 

20th. Calomel and antipyrine are incompatible, as are also sweet 
spirit of nitre and antipyrine. 

21st. Waters cannot be used in preparing saturated solutions of 
drugs, as they are already loaded with the volatile substance. 

22d. Pepsin and pancreatin should not be used together, since the 
former can only act in an acid and the latter in an alkaline medium, 
and the pancreatin is destroyed by the acid gastric digestive process. 
Further, one ferment may neutralize the other. 

THE IMPORTANCE OF DIETETIC TREATMENT. 

Many physicians fail to pay proper attention to the regulation of 
the diet when treating those who are ill or "out of sorts." As a 
matter of fact, the administration of medicine often fails to produce 
good results simply because the patient, by persisting in the use of 
improper food and drink, is perpetuating the difficulty of which he is 
trying to get rid of. There is scarcely a case in which some regulation 
or alteration of the diet will not be of advantage to the sick man. 
(See Foods for the Sick.) Further than this, failure to give direct- 
ions as to diet is apt to give the patient the idea that the physician 
is careless, whereas care in this respect will greatly enhance his 
estimate of the physician's ability to attend to important details of 
the case. 

PRESCRIPTION WRITING. 

When a physician directs a patient how to regulate his diet, what 
exercise he is to take, and how many hours a day are to be devoted 
to recreation and work, he prescribes for him quite as much as when 
he writes a prescription calling for one or more drugs which are to 
be dispensed by the druggist and swallowed by the individual who 
is ailing. Nevertheless, the word "prescription" is usually applied 
to the piece of paper on which is written the physician's order to 
the druggist. 

In writing prescriptions physicians usually employ Latin terms. 
There are several reasons for this. In the first place, it is a custom 
which has been followed since the time when medical science^was 
in its infancy, and medical men were wont to write what they had 
to say in Latin. Secondly, the botanical names of plants are usually 
in Latin: first, because scientific men give them their names, and 



PRESCRIPTION WRITING 01 

second, because not infrequently the English name for a plant 
in one part of a country has an entirely different application in 
another. Thus nearly every State has a drug called " Snake-root," 
yet in each instance a different plant may be so designated. Again, 
it is often advisable that a patient be kept in ignorance of the char- 
acter of the drug which he is taking, lest he attempt to use it without 
a physician's advice on another occasion, and thereby do himself 
injury. Thus the physician might wish to give a patient a dose of 
coca as a powerful nervous stimulant, yet would fear that it might 
be taken without advice later, and do harm. By using the word 
" Ery throxylon" the druggist knows what to dispense, but the 
patient does not recognize the term used and fails to remember it. 

All prescriptions should be written on sheets of paper on which 
are printed the physician's name, address, and office hours. This 
information is obviously necessary, and particularly is it useful to 
the druggist, who may wish to communicate with the physician in 
case he thinks that a poisonous dose has been ordered by mistake. 
The name and address of the patient should be written on the pre- 
scription-blank, so that the druggist may know where the medicine 
is to be sent when it is prepared. The prescription is to be accurately 
dated. 

The symbol or mark placed on a prescription-blank after writing 
the name of the patient and his address is "Ify," which stands for 
"Recipe," which is the second person singular of the imperative 
present of the Latin verb "Recipio," meaning "I take." Recipe or 
1$, therefore, says to the druggist "Take thou" of whatever sub- 
stances the physician desires. As he is to take a given quantity of 
his stock and place it in the mixture, the name of the drug is put in 
the partitive genitive case. When, however, a pill or other finished 
or complete product is ordered, so that not part of the stock, but the 
whole article is desired, the name of the medicine is placed in the 
accusative case, since it is the object of the verb. 

The nouns or names of drugs belong to one of the five Latin declen- 
sions, and are most of them declinable. Those of the first declen- 
sion end in the letter "a" in the nominative singular, and in "se" in 
the genitive singular, or "arum" in the genitive plural, except in 
the case of the word aloe, the genitive singular of which is aloes. 
Thus aqua is the nominative, aqua is the genitive singular, and 
aquarum is the genitive plural. 

The nouns of the second declension end either in "us" if mascu- 
line, or "urn" if neuter. Their genitive singular ends in "i" and 
the genitive plural in "oram." There are several nouns of this 
declension which end in "on," like "hematoxylon," which also end 
in "i" in the genitive singular. Thus we find that Syrupus is the 
nominative, Sympi the genitive singular, and Syruporum the genitive 
plural. 

In the third declension the nouns end in a, e, i, o, y, c, 1, in, r, s, t, 
and x. The genitive singular ends in "is" and the genitive plural 



62 GENERAL THERAPEUTICAL CONSIDERATIONS 

in "um." Thus, /Ether in the genitive is Mtheris, and the genitive 
plural Mtherum. When the noun ends in "s" the genitive takes a 
"t" before the "is." Thus boras is the nominative singular, boratis 
the genitive singular, and boratum the genitive plural. 

In the fourth declension the masculine nouns end in "us," and 
the neuter nouns in "u." The genitive singular of the masculine 
noun ends, as does the nominative, in "us," and the neuter noun like 
the nominative ends in "u," while the genitive plural ends in "um." 
Thus, Spiritus, of which the nominative singular ends in "us," is 
spiritus, in the genitive singular and spirituum in the genitive plural. 

In the fifth declension the nominative singular ends in "es," the 
genitive singular in "i," and the genitive plural in "rum." Thus, 
Res has as its genitive singular rei, and as its genitive plural rerum. 

Adjectives used to qualify nouns agree with them in gender, 
number and case. 

After the ingredients and their quantities have been signified the 
physician expresses his wishes further, and writes the word "Misce," 
"mix," the ingredients. If the prescription is put up in fluid form, 
he next writes the signatura, and writes the word Signa, usually 
abgreviated by Sig., which tells the druggist to write the directions, 
which follow in English, on the label of the bottle. 

If the prescription consists in a powder and is to be put up in 
papers, after the word Misce, or the letter "M.," which stands for 
Misce, the physician adds et divide in chartulas No. xx.— that is, 
divide into twenty small papers or powders. If pills are desired, 
he writes M. fiant (often written "ft.") pilulce No. xx.— that is, 
make into 20 pills. 

Or fiat unguentum, let an ointment be made. 

Or the imperative may be used by the employment of the word 
fac, &sfac suppositorias numero v.— that is, "Make thou 5 supposi- 
tories." 

If capsules are desired, the druggist is directed to mix the ingre- 
dients, and the physician adds et pone in capsulas No. xx.— that is, 
mix and put into 20 capsules. 

A prescription is often composed of a basis or the drug that is 
most important, an adjuvant or the drug to aid the basis, a correc- 
tive to overcome some effect which is undesirable, and a vehicle to 
give bulk and to carry the active substances into the body. After 
the name of the vehicle, which is also designed to bring up the 
mixture to an even quantity, we add the words quantum sufficit ad 
(a sufficient quantity to), usually abbreviated to "q. s. ad," to make 
the number of ounces desired. 

A complete prescription may therefore be written as follows: 

For Mr. John Jones, 111 Bank Street. 
October 31, 1907. 

]$ — Bismuthi subnitratis gr. xl 

Creosoti lUx 

Misce et pone in capsulas No. xx. 
S. — Take one after each meal. 



PRESCRIPTION WRITING 



63 



Or 

1$ — Acidi sulphurici aromatici f5ij 

Fluidextracti haematoxyli f5iv 

Spiritus chloroformi f 5j 

Syrupi zingiberis q.s. ad f giij 

Misce. 

S. — Take 1 dessertspoonful in water every three hours. 

In the last prescription the sulphuric acid is the basis, the hema- 
toxylon and spirit of chloroform are the adjuvants, and the syrup 
of ginger is the vehicle. 



Latin Word. 


Abbreviation 


Ad. 




Ad lib'itum. 


Ad lib. 


Adde. 


Add. 


Ana. 


A., aa. 


Aqua bul'liens. 


Aq. bull. 


Aqua destilla'ta. 


Aq. dest. 


Aqua fonta'na, fervens. 


Aq. font., ferv. 


Aqua pluvia'lis. 


Aq. pluv. 


Aqua'lis. 




Bene. 




Bis in dies. 


Bis in d. 


Bulliat, bulliant. 


Bull. 


Cape, capiat. 


Cap. 


Cap'sula. 


Caps. 


Cera'tum. 


Cerat. 


Char'ta (karta). 


Chart. 


Chartula (kartula). 


Chart. 


Cibus. 


Cib. 


Cochle'are magnum. 


Coch. mag. 


Cochle'are parvum. 


Coch. parv. 


Cola, colatus. 


Col. 


Colluto'rium. 


Collut. 


Collyr'ium. 


Collyr. 


Compos'itus. 


Co., Comp. 


Confec'tio. 


Conf. 


Con'gius. 


C. 




C.c. 



Cum. 

Dilute, Dilu'tus. Dil. 

Dimid'ius. Dim. 
Divida'tur in partes eequales. D. in p. seq. 

Div'ide. D., Div. 

Dividen'dus. Dividend. 

Do'sis. Dos. 

Extend'de supra. Exten. sup. 

Fac, fiat, fiant. F. 

Fil'trum, Filtra. Fil. 

Gargaris'rua. Garg. 

Grammum, Gramma. Gm. 

Gutta, Guttse. Gtt. 

Gutta'tim. Guttat. 

Haus'tus. Haust. 

Hora. H., Hor. 

In dies. Ind. 
Lage'na (lajena). 

Libra. lb. 
Lo'tio (losheo). 

Mag'nus. Mag. 

Mane primo. Mane pr. 

Mas'sa. Mass. 

Mica pa'nis (mika). Mic. pan. 

Misce. M. 

Mistu'ra. Mist. 



Translation. 
To, up to. 
At pleasure. 
Add (thou). 
Of each. 
Water, boiling. 
Water, distilled. 
Water, spring, hot. 
Water, rain. 
Pertaining to water. 
Well. 

Twice daily. 
Let boil. 

Take. Let him take. 
A capsule. 
A cerate. 

A paper (medicated). 
A little paper for a powder. 
Food. 

A tablespoon. 
A teaspoon. 
Strain. Strained. 
A mouth- wash. 
An eye-wash. 
Compound. 
A confection. 
A gallon. 
A cubic centimeter or cubic cen- 

timers. 
With. 

Dilute (thou), diluted. 
One-balf. 

Let it be divided into equal parts. 
Divide (thou). 
To be divided. 
A dose. 
Spread upon. 
Make, let be made, let them be 

made. 
A filter. Filter (thou). 
A gargle. 
A gram, grams. 
A drop, drops. 
Drop by drop. 
A draught. 
An hour. 
Daily. 

A flask or bottle. 
A pound, a Troy pound. 
A lotion. 
Large. 

Very early in the morning. 
A pill-mass. 
A crumb of bread. 
Mix. 
A mixture. 



64 



GENERAL THERAPEUTICAL CONSIDERATIONS 



Latin Word. 


Abbreviation. 


Translation. 


Nox, Nocte'maneque. 




Niglit, at night a::d in the morn 


Nurnerus, Nuuiero. 


No. 


mg. 
A number, in number. 


Octarius. 


0. 


A pint. 


Pars. 


Par. 


A part (governs genitive). 


Partes sequales. 


P. se. 


Equal parts. 


Parvus. 


Parv. 


Small. 


Pediluviutn. 




A foot-bath. 


Pencillium cameliuuui. 


Pencil, cam. 


A camels' -hair pencil or brush. 


Per fistulain vit-reani. 




Through a glass tube. 


Phiala. 


Phil. 


A vial. 


Pro re nata. 


P. r. n. 


According to circumstances, occa 
sionally. 


Quantum sufficiat. 


Q. s. [followed by gen- 
itive). 


As much as is necessary. 


Quaqua bora. 


Q. h. 


Every hour. 


Saturatus. 


Sat. 


Saturated. 


Scatula. 


Scat. 


A box. 


Secuncia. 


Secunc. 


An ounce and a half. 


Semidrachma. 


Semidr. 


A half-drachm. 


Sernissis. 


Ss. 


A half. 


Signa. 


S., Sig. 


Sign. 


Sine. 




Witbout. 


Solutio. 


Sol. 


A solution. 


Solve, Solatus. 


Solv. 


Dissolve, dissolved. 


Spiritus. 


Spr. 


A spirit. 


Statini. 


Stat. 


Immediately. 


Talis. 


Tal. 


Such, or like. 


Tere simul. 


Ter. sim. 


Rub together. 


Ter in die. 


T. i. d. 


Three times a day. 


Vehiculum. 


• Veliic. 


A menstruum. 


Yitello ovi solutus. 


V. o. s. 


Dissolved in the yolk of an egg. 


Vitellus 


Vit 


The yolk (of an egg). 



PART II. 

DRUGS. 



ACACIA. 



Acacia, U. S., Acacia? Gummi, B. P., Gum Arabic or Gum Acacia, 
is a gummy exudate from the stems and branches of small trees 
known as Acacia Senegal, and other acacias growing in Northern 
Africa and in Australia. As sold in the stores it consists of round- 
ish tears of various sizes, or broken into angular fragments; whitish 
or yellowish-white, translucent; very brittle, with a glass-like, some- 
times iridescent fracture; nearly inodorous; taste insipid, mucilagin- 
ous; insoluble in alcohol; slowly and completely soluble in water, 
forming an odorless, mucilaginous liquid. 

Acacia is devoid of physiological action. 

Therapeutics.— Acacia is employed in medicine as a local applica- 
tion to inflamed and irritated mucous membranes, particularly of the 
upper air-passages, and also, when dissolved in water, in the form 
of a drink when the same conditions exist in the mucous membranes 
of the alimentary canal. In all these states it is useful as a vehicle 
for more powerful remedies. Made into a mucilage with flaxseed, 
to which liquorice may be added, it is largely employed as a drink 
to loosen a hacking cough in children or in adults. The flaxseed 
should not be boiled, but allowed to stand on a moderately warm 
part of the "range," and the gum-arabic solution added with a little 
lemon-juice for flavoring purposes. It is also used in solution intra- 
venously in shock and profuse hemorrhage. (See Intravenous Injec- 
tions, Part III.) Acacia is chiefly used in pharmacy for making pills, 
emulsions and similar preparations, and is official in the form of the 
mucilage of acacia (Mucilago Acacia?, U. S. and B. P.) and the syrup 
of acacia (Syrupus Acacia?, U. S.), the first containing 340 grams 
of acacia, lime-water 330 grams and water enough to make 1000 
grams, and the second 25 cc of the mucilage to 75 cc of simple 
syrup. 

Acacia is incompatible with 60 per cent, alcohol, subacetate of 
lead, ferric chloride and borax. 

5 (65) 



66 DRUGS 



ACETANILID. 



Acetanilidum, U. S. and B. P., is the monacetyl derivative 
[C 6 H 5 NH(CH 3 .CO)] of aniline. 

It occurs as colorless, shining, micaceous, crystalline laminae, or 
a crystalline powder; odorless, having a slightly burning taste, and 
permanent in the air. It is soluble in 190 parts of water and in 
3.4 parts of alcohol at 25° C. (77° F.); in 20 parts of boiling water 
and in 0.6 part of boiling alcohol; also soluble in 17 parts of ether 
and 3.7 parts of chloroform at 25° C. (77° F.). It is made by the 
action of glacial acetic acid upon aniline, forming acetanilid or 
phenyl-acetamide. The word antifebrin is a registered name, and 
its use should be avoided by the profession, since its employment 
obliges the druggist to use the acetanilid made by one firm instead 
of the drug made by other chemists who manufacture it as an ordi- 
nary chemical compound, and do not charge so high a price as do 
those who market the product under a registered name. 

Physiological Action.— Acetanilid has been studied experimentally 
and clinically to a very great extent, and fairly definite outlines 
of its action have been mapped out. 

Nervous System.-— On the nervous system acetanilid has been 
found to act as a sedative, the sensory portion of the nerves and 
spinal cord particularly being quieted. After a poisonous dose 
general anesthesia comes on, with total loss of reflex action and 
with motor and sensory paralysis. The portions of the nervous 
system affected in these changes are, primarily, the sensory side of 
the spinal cord and the sensory nerves, the motor apparatus being 
least influenced. The muscles are only indirectly influenced by the 
poison. 

Circulation.— On the circulation acetanilid has but little direct 
influence except when used in poisonous doses. Applied to the 
frog's heart, it at first accelerates its beat and increases its force, 
but soon causes a weakening, ending with arrest in wide diastole. 
Upon the higher animals it causes, in toxic dose, an immediate 
fall of arterial pressure with a diminution in the size of the pulse- 
waves and all the evidences of cardiac and circulatory depression, 
notwithstanding the fact that death ensues from respiratory failure. 
The cause of this fall of blood-pressure is a direct depressing action 
on the heart associated with failure of the vasomotor system, as 
asphyxia causes no rise in pressure. 

In medicinal dose acetanilid causes no circulatory changes of 
moment in the healthy individual. Sometimes the pulse-rate is 
increased, sometimes diminished. The tendency is, however, toward 
depression rather than stimulation of the circulation. 

Blood.— When used in large doses, the action of this drug upon 
the blood is more pronounced than its influence upon any other part 
of the body, causing this tissue to become brownish red, decreasing 



ACETANILID 67 

its oxygen-carrying power, and, finally, reducing the hemoglobin to 
methemoglobin to a very considerable extent. The question as to 
the influence of acetanilid upon the corpuscles is still undecided 
some observers declaring that these bodies are disorganized, while 
others assert that they remain intact. In moderately large poison- 
ous doses it may not affect the corpuscles, but if its use in large 
amount be continued for some days, or a very large amount be used 
at one time, corpuscular destruction certainly occurs, free hemoglobin 
appearing in the urine in its characteristic forms. The normal alka- 
linity of the blood is decreased, and the urine becomes dark and 
brownish in color, and the blood-crystals of Teichmann are found 
in it. In medicinal doses the blood shows no change except in cases 
where idiosyncrasy is present or the doses are unusually large. Under 
these circumstances the blood in the arterial system becomes darker 
than normal. 

Respiration.— No effect is produced upon this function by 
acetanilid when given in moderate doses. When poisonous doses are 
used, the breathing at once becomes rapid and labored. Large doses 
produce death by paralysis of the respiratory centers. These effects 
are primarily due to the alterations in the blood, which so influence 
oxygenation of the tissues as to spur the respiratory centers to greater 
effort, while at the same time it is beginning to be directly depressed 
by the drug itself, so that impairment of its function is soon manifest. 
Bokai asserted that the drug paralyzes the peripheral motor nerves, 
which, if true, brings forward a third factor in the respiratory failure. 

Temperature.— When given in full medicinal doses, acetanilid 
lowers the normal bodily temperature or else fails to produce any 
change. In poisonous doses it produces a decrease in temperature 
depending on the amount employed, and may cause collapse and 
rigors. On a fever temperature it acts as a powerful and fairly 
constant antipyretic, lowering the fever by decreasing heat-production 
and increasing heat-dissipation, heat-production being the function 
most affected. 1 Whether the decrease in heat-production is due to 
an action on the heat-centers in the nervous system, or upon other 
causes is not known. Some investigators have claimed that the fall 
depends upon the partial reduction of the hemoglobin of the blood, 
whereby less oxygen is carried to the tissues and less combustion 
ensues. This seems doubtful in view of the fact that spectroscopic 
examination of the blood fails to show any such change from the use 
of medicinal doses. That the fall of temperature is not dependent 
on the sweat produced is proved by the fact that the temperature 
falls even if enough atropine is given to stop all perspiration. 

Kidneys, Tissue-waste and Urine.— Much contradictory evi- 
dence exists in regard to the changes which occur in these organs 
and their excretory products under the influence of acetanilid, but 

1 The author's reasons for holding to the opinions stated can be found in his BovLston 
Prize Essay of Harvard University, on Antipyretics. 



68 DRUGS 

most observers agree that the excretion of urea is increased (Lepine, 
Chittenden and Taylor). Less uncertainty exists as to its influence 
on the elimination of uric acid, which is increased rather than dimin- 
ished by the drug. After excessively large doses the urine becomes 
dark from the presence of broken-down blood-coloring matter. 

Elimination.— The drug is eliminated by the kidneys as para- 
amido-phenol sulphate, and is entirely passed out of the body in about 
twenty-four hours. 

Antiseptic Action.— Acetanilid possesses distinct antiseptic powers, 
but is not capable of acting as a disinfectant. (See Therapeutics.) 

Toxic Changes from Prolonged Use.— Although it has been asserted 
that no untoward effects result from the constant and prolonged use 
of acetanilid in large doses, there can be no doubt that this assertion 
is untrue. Used constantly in excess, congestion of the liver, kid- 
neys and spleen occurs, and if the dose be poisonous, clots may be 
found in the cardiac cavities. There may be also a progressive 
decrease in the number of the red blood corpuscles. On the other 
hand the popular idea that its fairly frequent use is deleterious is 
in the great majority of cases false. 

Poisoning.— In man this drug in toxic quantity causes the lips to 
become blue and the face livid, cyanosed, expressionless, or anxious. 
The forehead and cheeks become covered with sweat, which gradu- 
ally extends over the rest of the body. The pulse is soft and com- 
pressible, but slow, and finally very weak. The respirations become 
slow and shallow. 

The treatment of a case of poisoning by acetanilid should con- 
sist in supporting measures, the use of stimulants, external heat, 
belladonna to maintain blood-pressure, strychnine to aid the respi- 
ration, and oxygen inhalations if they are necessary to combat cyanosis. 

Therapeutics.— The employment of acetanilid in fevers must 
depend very much upon the condition of the patient and the char- 
acter of his disease. The mere existence of a high temperature is 
not, correctly speaking, an indication for any antipyretic remedy. 
The phase of the disease must be recognized, and the question as to 
whether the fever which is present is harmful must be duly weighed. 
(See Treatment of Fever, Part IV.) 

In typhoid fever, though the drug possess decided antipyretic power, 
it often causes great depression and collapse, and in no way influences 
favorably the duration or general course of the disease. 

For the same reasons the use of acetanilid in phthisis is inadvis- 
able, for, although it greatly affects the hectic fever, it is very apt 
to cause collapse, profuse sweating and depression. Thus, the writer 
has repeatedly seen cases of phthisis in which the attempt to control 
the fever by this drug resulted in the symptoms just named; and 
Riese points out, what the author has also noted, namely, that in 
this disease cyanosis is very apt to come on after the use of the drug. 

In regard to the employment of acetanilid in sthenic fevers, it at 



ACETANIL1D 69 

once becomes evident that a drug absolutely unsuited to a case of 
asthenic disease may, on the other hand, agree with a sthenic-fever 
patient very well. In consequence of this, we find that the sweating 
produced by acetanilid is not so marked or troublesome in diseases 
of a dynamic type, and that, in consequence, it more rarely causes 
collapse; but even in this class of cases, and particularly in both 
varieties of pneumonia, the use of acetanilid is rarely advisable. 
Indeed, the antipyretic use of this and similar compounds is yearly 
becoming less and less. 

In much the same manner that antipyrine was found, some time 
after its introduction, to be possessed of pain-relieving power, so 
acetanilid has been discovered to possess similar properties. Almost 
every form of nerve-pain seems to indicate its employment. It has 
been successfully used in the crises of ataxia, the severe dartings of 
neuralgia, in cases of sciatica, and severe headaches often yield to its 
influence. Experience has proved it to be of value in epilepsy. 

The employment of acetanilid in acute rheumatism may be sepa- 
rated, if desired, into that devoted to the relief of pain and the 
reduction of pyrexia. There can be no doubt whatever of the ability 
of the drug to control the fever of this disease, and the question as 
to whether it favorably influences the severity of the pain of the 
malady is to be answered strongly in the affirmative. It is not 
curative. (See Rheumatism, Part IV.) The dose for cases of rheu- 
matism should be 4 (0.25) to 6 (0.4) grains three times a day. In 
subacute rheumatism of the muscular type, acetanilid will often give 
marked relief. 

Acetanilid in dry powder is of value in the treatment of chancroids, 
and in the antiseptic dressing of wounds when used alone or with 
equal parts of borax. 

In many cases of obstinate vomiting t particularly that following 
surgical operations when an anesthetic has been used, acetanilid is 
a useful remedy. The drug is usually best given in the dose of 1 
grain (0.06) every half -hour until 6 grains (0.4) have been taken; 
and the following prescription may be used in compressed tablet, 
pill, or powder, preferably the latter, in order to increase the sedative 
effect on the stomach and support the heart. 

fy — Acetanilidi gr. vj (0.4) 

Fiant pilulse vel chartulse, No. vi. 
S. — Wash down with a little water or else dissolve powder in a dram of brandy, 
pour over cracked ice and give it slowly from a spoon. 

Acetanilid has been recommended as a local hemostatic in epis- 
taxis, and has been given internally with asserted advantage in 
hemoptysis. This use is probably erroneous. 

Acetanilid distinctly increases the susceptibility of a patient to 
cold, and for this reason it should not be used for the relief of neu- 
ralgic or other pain before leaving the house in cold weather if it 
can be avoided. 



70 DRUGS 

Incompatibility.— Acetanilid is decomposed by strong alkalies, and 
alkaline iodides and bromides in aqueous solution precipitate it. It 
forms a soft mass or liquid with hydrated chloral, with phenol, 
resorcinol, thymol and antipyrine. 

Untoward effects are not common if acetanilid be used with care. 
The writer has collected a number of cases (thirty-eight) in which 
unfavorable signs appeared after its use, but untoward action was 
never seen unless the dose given was excessive for the case which 
received it. The dose most commonly producing such symptoms 
was from 3 (0.2) to 10 grains (0.6). In only three instances of the 
series did death occur— one from heart-clot and two from excessive 
dosage. No deaths were reported from moderate amounts, although 
some of the cases were alarming. Very rarely symptoms of poison- 
ing by acetanilid such as are described above follow its general use 
as a dusting-powder over wounds and other breaks in the skin. 

Administration.— Acetanilid may be given in doses varying from 
2 (0.12) to 10 grains (0.6), the last-named amount being usually 
excessive. As it is virtually insoluble in water, it should always be 
administered in wine or spirit, in which it is soluble, or in powders, 
capsules or pills. The antipyretic effect is manifested about one 
hour after the drug is taken. When neuralgias are to be treated 
or similar forms of pain are present, one of the bromides, in the 
dose of 10 grains (0.65), may be combined with acetanilid with 
advantage. 

This drug is not to be used if there is reason to believe that marked 
renal congestion or irritation is present. 



ACETIC ACID. 

Acidum Aceticum, U. S. and B. P., is a clear liquid, composed of 
not less than 36 per cent, nor more than 37 per cent, of glacial acetic 
acid, having a strong characteristic, vinegar-like odor, a sharply acid 
taste, and a strongly acid reaction. Miscible with water or alcohol 
in all proportions. It is obtained from wood by destructive distilla- 
tion, or by the oxidation of ethyl alcohol. 

Acetum, or Vinegar, is practically dilute acetic acid. 

Therapeutics.— Acetic acid is seldom used internally. The glacial 
or absolute acetic acid (Acidum Aceticum Glaciate, U. S. and B. P.) 
is used as a powerful escharotic. It may be applied to warts and 
other growths, and to old sores where the granulations are profuse 
and healing is slow. The dilute acid (Acidum Aceticum Dilutum, U. 
S. and B. P.) is used as a lotion in night-sweats and to arrest epistaxis 
and other minor hemorrhages. When employed as a lotion it should 
be diluted one-half with water. Vinegar, or dilute acetic acid, has 
been used internally to decrease obesity, but is a harmful and useless 
remedy, disordering digestion and reducing the patient's strength. 



ACETPHENETIDIN 71 

Inhalation of vinegar fumes from a cloth saturated with this liquid 
sometimes will control vomiting after the use of an anesthetic. 

In the following mixture acetic acid may be used for the removal 
of vegetations about the external genitals: 

1$ — Acidi salicylici gr. xxx (2.0) 

Acidiacetici f§j (30.0).— M. 

S. — Apply with a camel's-hair brush. 

Only slight pain is caused by this application. 

Poisoning.— When overdoses of acetic acid are taken, the treat- 
ment consists in the use of large draughts of milk, alkaline liquids, 
such as lime-water, soap-water, etc., and the general measures suit- 
able for the treatment of gastro-enteritis. (See Gastro-enteritis, 
Part IV.) 

Contraindication. — Nursing mothers should not take freely of 
vinegar, as it may produce a troublesome diarrhea in the nursling. 

ACETPHENETIDIN (PHENACETIN) . 

Phenacetin (Acetphenetidinum, U. S.; Phenacetinum, B. P.) is a 
coal-tar product introduced several years ago as an antipyretic of 
the same character as acetanilid. It occurs in white, glistening, 
crystalline scales without odor or taste. It is only slightly soluble 
in water. Acetanilid and antipyrine are sometimes substituted for 
phenacetin. Pure phenacetin when shaken with nitric acid is colored 
yellow, which color persists when it is heated. This is not the case 
with the other products named. 

When this drug is carelessly made, an impure product is the result, 
which produces irritation of the kidneys, and, in consequence, causes 
grave complications. Reuter states that the impurity may be dis- 
covered by placing a small amount of chloral hydrate in a test-tube, 
melting it at a temperature just sufficient to liquefy it, and then add- 
ing the suspected sample of phenacetin in the proportion of one-fifth. 
If the phenacetin is impure, it will become purple, then red, and 
finally blue. 

Physiological Action.— Unfortunately, our knowledge of the physio- 
logical action of phenacetin upon the nervous system is not so thor- 
ough as is desirable. We know, however, that it is a distinct nerv- 
ous sedative, and that it acts particularly on the spinal cord in its 
sensory tracts. 

Upon the circulation the drug has little or no effect unless given 
in doses exceeding those generally employed, or continued in overdose 
for some time. The blood after the ingestion of these doses becomes 
dark and blackish from the formation of methemoglobin, and the 
urine becomes dark yellow and reacts with Fehling's solution. Upon 
normal bodily heat and the heat of fever the drug exerts a depressing 
effect, decreasing the production and increasing the dissipation of 
heat. 



72 DRUGS 

Therapeutics.— Our knowledge concerning the influence of phen- 
acetin upon the human body in disease may be divided into two 
separate parts in much the same manner that we divide the uses of 
acetanilid— namely, its uses as an antipyretic and as an analgesic. 

The remarks made in the article on Fever (Part IV) clearly show 
why phenacetin should not be used as an antipyretic, for every drug 
used as an antipyretic is, as a rule, deleterious. It is far better to 
reduce the fever with cold applications. (See Cold in Fevers, Part 

in.) 

Upon the nervous system phenacetin acts as an antineuralgic, and 
is of service in migraine and ordinary headache from eye-strain, in 
the pains of tabes dor satis, in intercostal neuralgia, and in rheumatism. 
Sometimes it relieves these troubles when antipyrine fails. Altogether 
we may consider phenacetin a rival of antipyrine in the power to 
relieve pain. 

For neuralgia the following prescription may be ordered: 

~Bj, — Acctphenetidini gr. x (0.6) 

Caffeinae citratse gr. v (0.3) 

Strontii bromidi gr. xx (1.3). — M. 

Pone in capsulas, No. v. 

S.— One or two capsules every hour while the pain lasts. 

In subacute rheumatism and in the lumbar or muscular pains of 
influenza a powder or pill of 4 grains (0.25) of phenacetin and 5 
grains (0.3) of salol, given three or four times a day, is most efficient. 

Under the name " '' Lactophenin," a nearly related compound of 
phenacetin is sometimes used for the same purposes. In phenacetin 
one atom of hydrogen is replaced by an acetic-acid radical; in lacto- 
phenin this atom of hydrogen is replaced by a lactic-acid radical. 
Similarly "citrophen" is made by replacing the atom of hydrogen by 
a citric-acid radical. It is also used as a substitute for phenacetin. 

The dose of these drugs is about the same as that of phenacetin, 
or a little larger, about 5 to 10 grains (0.3-0.6) three times a day. 

ACOINE. 

Acoine is a synthetic substance introduced into ophthalmic surg- 
ery as a local anesthetic and antiseptic. It is used in a 1 or 2 per 
cent solution. It is a powerful anesthetic to the conjunctiva, but 
does not anesthetize the cornea and for this reason is useless when 
foreign bodies are to be removed from the cornea. 

ACONITE, OR MONKSHOOD. 

The aconite of the U. S. and B. P. is the dried tuberous root of 
Aconitum Napellus Linne (Fam. Ranunculacece) , collected in autumn; 
yielding, when assayed by the process given in the U. S. P., not less 
than 0.5 per cent, of ether-soluble alkaloids of Aconite. 



ACONITE, OR MONKSHOOD 



73 



Aconite is indigenous in Germany, France and Switzerland, and 
is cultivated as a garden-plant in Europe and America. The root 
resembles so strikingly that of horseradish as to be readily confused 
with that condiment, but does not emit the pungent fumes of the 
latter when it is scraped or broken. It is also to be remembered that 
aconite produces a sensation of heat in the mouth when chewed. 
The active principle upon which the therapeutical value of aconite 
would appear to depend is aconitine, but there is reasonable doubt 
whether this can be relied upon as completely as the preparations of 
the crude drug; the aconitine of commerce, moreover, varies very 
much in strength, because some of it is amorphous and impure, while 
other samples are pure and crystalline. Further than this, even the 
crystalline form is exceedingly variable in strength. In addition to 
aconitine, Dunstan asserts that 
there are two amorphous alkaloids 
— namely, benzaconine and aconine. 
Aconitine is 200 times as toxic as 
benzaconine and 2000 times as 
toxic as aconine. 

Physiological Action.— When aco- 
nite is placed on the tongue it 
produces a sensation of tingling 
and burning which extends over the 
pharyngeal surface, and into the 
stomach if the drug is swallowed. 
This is due to its primary irritant 
and secondary benumbing action 
on the sensory nerve-endings of 
the mucous membrane. It some- 
times causes a sensation of con- 
striction in the fauces. 

Nervous System.— In full medi- 
cinal dose aconite depresses the 
functional activity of the percep- 
tive centers in the brain, and the sensory side of the spinal cord, 
but chiefly depresses the peripheral ends of the sensory nerves. 
Applied to a mucous membrane, it acts as a local anesthetic, but is 
too irritating for this use in the eye. On the motor portion of the 
body it exerts little influence unless given in poisonous doses, when it 
paralyzes the motor tract of the spinal cord and the peripheral motor 
nerves. 

Circulatory System.— When aconite is given in moderate medi- 
cinal dose it exercises no marked effect on any part of the organism 
save the circulation, which becomes somewhat slower from stimula- 
tion of the vagus centers and by the drug acting as a sedative to the 
heart-muscle itself. This cardiac slowing is caused has been denied 
by Price, but my experience is that it does occur. The arterial 




Fig. 5. — A, vagus center stimulated 
by aconite, which slows pulse; B, heart 
muscle depressed, which slows pulse; c, 
vasomotor center depressed, which 
lowers arterial tension; d, respiratory 
center depressed. 



74 DRUGS 

pressure is slightly decreased by these doses, chiefly by the decrease 
in cardiac force. If large doses are used, the heart becomes still 
more feeble and slow, and the arterial pressure falls from this cause 
and from depression of the vasomotor center. When a poisonous 
dose is given, it causes first a marked fall in pulse-rate and arterial 
pressure, preceded sometimes by a quickening due to a condition of 
weakness and abortive cardiac action: this condition gradually 
passes into diastolic arrest of the heart, the viscus becoming para- 
lyzed and refusing to respond to stimuli. 

Respiration.— In moderate doses aconite quiets the respiratory 
movements slightly, particularly if the breathing is hurried. In 
poisonous doses it paralyzes the respiratory center and so causes 
death. 

Temperature.— Aconite acts as a distinct reducer of fever, prob- 
ably because of increased heat-radiation arising from relaxation of 
the capillaries and impaired circulation. 

Absorption and Elimination.— Aconite is rapidly absorbed and 
destroyed by oxidation, so that its effects do not last for any length 
of time. The effect of aconite when given in a large medicinal dose 
lasts for about three hours. It usually increases the urinary flow. 

Poisoning.— When aconite is taken internally in excessive amount, 
it causes tingling of the mucous membranes wherever it touches them, 
which sensation finally amounts to severe burning. This soon passes 
away, and is followed by a sense of tingling about the lips and finger- 
tips or all over the skin. At the same time the patient feels relaxed; 
the pulse at first becomes weak and slow, but later may be rapid and 
running, so that it seems a mere trickle under the finger; sweating is 
more or less marked and fainting may ensue. Vomiting may occur, 
but is rare. The respirations now become slow and shallow, seeming 
to expand the lung to the smallest possible extent consistent with 
life. The face is pallid and anxious. Consciousness is preserved 
unless lost through an attack of syncope. There may be exophthal- 
mos, or the eyes may be sunken and dull. The sclerotic is pale and 
pearly-looking. There is excessive pallor of the face. Clonic con- 
vulsions of unknown origin sometimes occur. There may be marked 
anesthesia of the skin. The pupils may be normal, contracted, or 
dilated widely. The temperature of the body is sub-normal. Death 
may be gradual or sudden, the slightest movement of the body 
which throws any strain on the heart stopping that organ in diastole. 

Treatment of Poisoning.— The patient is to be placed on 
the back on a bed or board, with the feet higher than the 
head, in order to confine the circulation as far as possible to the 
vital centers at the base of the brain. Hot bottles or bricks are to 
be placed about the body for the purpose of maintaining the bodily 
heat. Emetics are not to be given if the symptoms are severe, as 
vomiting may cause cardiac failure, owing to the muscular effort 
involved, or the stomach may be so depressed that emetics will not 



ACONITE, OR MONKSHOOD 75 

act. If vomiting comes on, the vomitus should be received into a 
towel, the patient not being allowed to raise his head. The stomach 
is to be washed out by means of a stomach-pump or a siphon of rubber 
tubing. Ether may be given hypodermically, spirit of ether, or 
aromatic spirit of ammonia, by the mouth, and this followed by 
digitalis. Full hypodermic doses of strychnine, such as ^ to y^ 
(0.003-0.006) grain, should be given to stimulate the respiration and 
heart. The ether acts at once, and stimulates until the digitalis, 
which is the physiological antagonist of aconite, but slow and more 
prolonged in its effects, asserts itself. Atropine, because of its 
stimulating effect on the vasomotor system, may also be used. If 
the breathing fails, artificial respiration is to be employed, or if the 
heart seems about to cease its action, a whiff of nitrite of amyl may 
start it going again; but only a few drops of the nitrite should be 
used, as large amounts depress this organ. 

Untoward Effects.— Aconite when applied locally or taken internally 
may cause in susceptible persons a vesicular, or even a pustular, 
eruption, or instead an intense itching of the skin may be developed. 

Therapeutics.— Aconite is used chiefly for its influence as a cardiac 
and circulatory sedative, for its effects on the peripheral sensory 
nervous system, as in the vomiting of pregnancy, and in those states 
in which, through inflammation elsewhere, the nervous system needs 
a sedative which will simultaneously reduce arterial tension. In the 
early stages of all acute inflammations aconite may be of service. 
Aconitine may be applied locally over superficial nerves in neuralgia 
in the form of an ointment (2 grains [0.12] to 1 drachm [4.0], or as 
the oleate of aconitine, 2 grains [0.12] of the oleate to 100 [6.6] of 
sweet oil). In the earlier stages of ^gonorrhea aconite in small doses 
frequently repeated is a valuable remedy, and later in the disease 
tends to prevent chord ee by its influence on the nervous centers. It 
is useful in croup, quinsy, sore-throat, severe colds, bronchitis, and 
asthma due to exposure, in their early stages. When suppression of 
menstruation follows exposure to cold, this drug given with a hot 
drink and a hot sitz-bath, will often restore the flow. In pericarditis 
it is valuable to allay the inflammation and quiet the excited heart. 
Aconite is by far the best circulatory and nervous sedative for 
children in the earliest stages of the sthenic fevers, particularly of 
the irritative type. 

Ifc — Tincturse acortiti Tfl.xx (1.3) 

Spiritus setheris nitrosi f3ij (8.0) 

Liquoris potassii citratis q. s. ad f gij (60.0) 

S. — Teaspoonful (4 cc) in water every hour or two for a child of five years. 

Aconite ought not to be used in adynamic, asthenic affections. It 
is harmful in prolonged acute diseases, such as scarlet fever, if con- 
stantly employed. 

In some persons who suffer from asthma which is preceded by 
coryza, aconite does good if given in the earliest stages. 



76 DRUGS 

In nervous palpitation of the heart and in the palpitation of exces- 
sive cardiac hypertrophy aconite is valuable. In many cases of this 
character, where there is not only hypertrophy but also impaired 
innervation, the use of a prescription containing aconite and digi- 
talis proves of service, for the minute doses of digitalis stimulate the 
vagus nerve, and the aconite not only steadies the heart by its 
stimulant effect on the vagus, but also prevents an overstimulant 
effect of the digitalis on the heart-muscle: 

1$ — Tincturae aconiti fgss (15.0) 

Tincturae digitalis f5ij (3.0) 

Tincturae belladonnae foliorum f5ij (8.0) 

Tincturae gentianae compositae .... q.s. ad f5iij (90.0). — M. 

S. — Teaspoonful every six hours. 

In the epistaxis of full-blooded people aconite often affords great 
relief. 

Administration.— As a general rule, small divided doses of the drug 
in the form of the tincture, 2 to 4 minims (0.1-0.2) given every 
fifteen minutes, will act better than a full dose given at once, unless 
the condition of the patient requires very active treatment. 

Preparations.— Tinctura Aconiti, U. S., should contain 0.045 gram 
to 0.055 gram of ether-soluble alkaloids in each 100 mils., and used in 
the dose of 3 to 20 minims (0.2-1.3). The tincture of the U. S. P. 
of 1910 is only 10 per cent, strength instead of 35 per cent, in former 
days. The dose of the B. P. tincture is 2-5 minims (0.12-0.3). A 
very useful way of employing it is in the form of tablet triturates. 
The extract of aconite (Extractum Aconiti, U. S.) is given in the dose 
of J to f grain (0.015-0.045). The fluidextract (Fluidextractum 
Aconiti, U. S.) is given in the dose of 1 to 2 minims (0.06-0.12). 
Fluidextract of aconite should contain about 0.5 gram of alkaloids 
in each 100 cc. Fleming's tincture ought never to be used. The 
dose of the active principle aconitine (Acontina, U. S. and B. P.) is 
4¥o to tut grain (0.00015^0.0003), but it ought never to be used 
internally. The B. P. preparations that are not official in the U. S. 
P. are aconitine ointment ( Unguentum Aconitinw) and aconite 
liniment (Linimentum Aconiti). 



ADALIN. 

Adalin, bromdiethylacetylcarbamide, is an odorless, almost color- 
less white powder, readily soluble in alcohol, but not in water. It is 
an efficient mental and nervous sedative closely resembling the ordi- 
nary bromides in power, and is a useful drug in cases of mild insomnia 
and nervous irritability. Taken for any length of time it sometimes 
causes skin lesions like the older bromides. The dose is 5 to 20 
grains (0.3-1.3) generally given in tablet form. 



AGARICIN 77 



ADONIS VERNALIS. 



From Adonis vernalis, a plant indigenous in Europe and Asia, is 
derived a glucoside, Adonidin. When given to one of the mammalia 
—the dog, for instance— it causes an increase in heart-force and a 
rise of arterial pressure. In the frog poisonous amounts arrest the 
heart in diastole. 

The indications for the use of adonidin are all conditions of car- 
diac failure, particularly the presence of cardiac dropsy. It is much 
inferior to digitalis and caffeine, but may be employed when these 
fail, as it sometimes succeeds under such circumstances. Adonis 
vernalis and the bromides have been combined m the treatment of 
epilepsy with asserted success. 

The dose of adonidin is J to J grain (0.008-0.015), three times a 
day; or 4 to 8 parts of the plant— all portions of which are employed 
—may be added to 180 parts of water, and of this infusion a half- 
ounce (16.0) may be given every four hours. 

AGAR. 

Agar, U. S., is a gelatinous substance obtained in Japan from 
several species of seaweed that grow on its coast. It is identical with 
the agar-agar used in the bacteriological laboratory and is used in 
medicine as a remedy for constipation. It possesses no physiological 
activity, so far as the general economy is concerned, and it does not 
exercise any true medicinal effect upon the intestine. By absorbing 
moisture it becomes swollen and soft and, by adding to the bulk of 
the intestinal contents, indirectly acts as a laxative in much the 
same type of cases as that in which mineral oil now is used. While 
it is of the nature of a carbohydrate, Mendel and others have shown 
that it is not attacked by the digestive ferments or the intestinal 
bacteria. Probably its greatest sphere of usefulness is in those cases 
of constipation in which the stools are unduly dry. Agar appears 
as a coarse granular powder and is given in the dose of from one to 
two heaping teaspoonfuls, or even one to two tablespoonfuls once 
or twice a day, eaten dry or mixed with some cereal or breakfast 
food. It can also be used in bread and biscuits. 

AGARICIN. 

Agaric, or Touchwood, or Punk, has been used in the Southern 
United States very largely in the dose of 5 grains (0.3) every few 
hours in the treatment of the night-sweats of phthisis; and agaricin, 
the alcoholic extract of the drug, has been used with asserted good 
results, under these circumstances, by certain German and English 
physicians, in the dose of from 1 to 2 grains (0.06-0.12) in capsule 
every five hours. Its physiological action is unknown, but it is 



78 DRUGS 

supposed to act upon the nerve filaments in the sweat-glands. The 
writer has employed it frequently in varying dose, and has never 
seen any decrease whatever produced by it in the sweats of phthisis, 
although he has watched its action most closely. Sometimes agaricin 
causes nausea and diarrhea. 

ALCOHOL. 

Ethyl Alcohol (Alcohol Ethylicum) is the only alcohol used in 
medicine. Some of the other alcohols are exceedingly poisonous. 
Amy lie alcohol is fusel oil. 

Alcohol is a liquid resulting from the fermentation of starches or 
sugars in the presence of heat. It is official in three forms— as 
Alcohol, U. S., containing 92.3 per cent, by weight of the spirit and 
7.7 per cent, of water; Alcohol Dehydratum, U. S., and Alcohol 
Absolutum, B. P., with not more than 1 per cent, by weight of water; 
and Alcohol Dilutum, U. S., or dilute alcohol, 41.5 per cent, by 
weight of spirit and the remainder water. The drug is generally 
given in the form of whisky or brandy, and when the word alcohol 
is used in the saying, "Give the patient alcohol," one of these two 
liquids is always meant unless it is otherwise stated. 

Notwithstanding the almost universal use of alcohol as a stimulant 
by the laity and the medical profession, it cannot be denied that evi- 
dence of scientific character and weight is constantly being brought 
forward which shows that its dominant action is depressant upon 
all parts of the body. It is claimed that under its influence the total 
amount of work accomplished in a given space of time is less than 
when it is not taken, and that the quickening of the pulse under its 
influence is not an evidence of strength. Nevertheless clinical exper- 
ience, too great to be ignored, stands for the continued employment 
of the drug. The drug does not act as a stimulant in the ordinary 
sense of the term, but nevertheless readjusts the circulation by dilat- 
ing the peripheral vessels and influences the protective powers of 
the body by affecting the blood cells or the blood serum or the 
lymph. This belief seems to find support by reason of experiments 
carried out by the author, in which he was able to show that alcohol 
produces a distinct increase in the bacteriolytic power of the blood 
in disease, probably by increasing the activity of the complemental 
body. These facts explain the good results which follow the use of 
the drug in clinical medicine. (See below.) 

Physiological Action.— Nervous System.— Alcohol never acts as a 
true stimulant to the brain, the spinal cord, or the nerves. On the 
contrary, its dominant influence is sedative. The increased activ- 
ity of thought and speech after its use is not due to stimulation, but 
to depression of the inhibitory nervous apparatus. The activity is 
therefore that caused by lack of control, and is not a real increase in 
energy. So far as the brain is concerned, it does not increase the 



ALCOHOL 79 

vigor of thought nor its depth, nor does it enable a man to work out 
a problem which is difficult. On the contrary, it rather benumbs 
the activity of mental processes and acts as a nervous sedative which 
is often advantageous. The effect of moderate doses differs from 
the effect of large ones in degree, but not in kind. Reflex action may 
be increased by the same depression of inhibition, but not by reason 
of any true stimulation of the cord. In large doses it produces lack 
of coordination by depression of the brain and lower nervous sys- 
tem, the loss of coordination being due largely to impairment of 
sensation, so that the sense of touch and the muscle sense are inter- 
fered with. This effect makes a drunken man fail to recognize the 
angles or uneven surface of surrounding objects, and the impaired 
mental power and disordered judgment, combined with the imper- 
fectly acting motor and sensory pathways, cause him to stumble 
and fall. 

Circulatory System.— Careful scientific research has proved that 
alcohol is in no sense a true stimulant to the circulation in healthy 
persons. Given in such a dilute form so that it cannot act as a local 
irritant to the stomach, it produces no change in pulse-rate or pulse- 
force. If the dose is large enough to cause any appreciable change 
in the activity of the circulation, it is in the nature of depression rather 
than stimulation. This is true in the laboratory and at the bedside. 
Alcohol does, however, produce very marked alterations in the 
distribution of the blood, as is seen in the flushing of the capillaries 
of the skin after its moderate use. In other words, it does not affect 
all the bloodvessels in a similar manner, for while the cutaneous ves- 
sels are dilated, those of the muscles are contracted, as are also those 
of the splanchnic area. The beneficial action following the use of 
alcohol in disease when it is thought to act as a stimulant probably 
depends upon the improved distribution of blood it produces, just 
as the use of the sponge bath or cold plunge in typhoid fever read- 
justs the circulation and restores vascular tone. Little if any effect 
is exercised by alcohol upon arterial pressure when given in medicinal 
dose. In very large toxic doses alcohol depresses and finally paralyzes 
the heart and vasomotor system. 

Respiration.— Respiration is not materially affected by alcohol. 

Temperature.— Alcohol never increases the number of heat units 
in the body, for though in its oxidation more heat is made than when 
no alcohol is used, the increased radiation, or loss of heat, from the 
skin and lungs under its influence more than counterbalances the 
gain caused by the drug. 

By its irritating effect on the mucous membrane of the mouth and 
stomach it produces a sensation of warmth, and warms the extremi- 
ties at the expense of the body by increasing the circulation of blood 
in those parts. This increase in the peripheral circulation is due to 
an increase in the rapidity of the flow of blood and to dilatation of 
the peripheral capillaries. If it be used to excess, the temperature 



80 DRUGS 

rapidly falls, owing to the increase of heat-radiation produced by the 
free distribution of blood, as has just been described, and secondarily 
by the depression of the vital forces, for in overdose alcohol always 
acts as a depressant. 

Bodily Metabolism.— The quantity of carbonic acid given off 
by the body under the use of alcohol is not materially altered. Some 
observers have noted an increase, some a decrease, and some no 
change at all when alcohol is taken. These results have probably 
depended upon the work required at the time the alcohol is in the 
body, for the influences of exercise and rest are potent factors in 
determining the activity of combustion or oxidation processes in the 
economy. The use of moderate doses of alcohol by a healthy man 
at first increases the loss of nitrogen, but after two or three days 
this effect passes off and there is a decrease in nitrogenous loss, the 
oxidation of the alcohol saving the tissues. Atwater and Benedict 
have shown that, owing to the ability of the body to oxidize alcohol, 
this liquid substitutes itself for the oxidation of fats and so saves 
tissue waste. The general effect of alcohol is, therefore, to conserve 
the body fat and the body proteids as well. That is to say, alcohol, 
by being burned up in the body, yields energy and saves tissue which 
would otherwise be oxidized if no alcohol were taken. To express 
it in still another way: alcohol, by its oxidation, adds force, not 
tissue, to the body, but by protecting the fats and proteids of the 
tissues from oxidation, it may cause an increase in weight if it is 
properly utilized by the body. 

This book is not the place for a discussion of the sociological aspects 
of the use of alcohol, but enough will be found in these pages to indi- 
cate that alcohol taken in youth, when nutritional processes are 
unimpaired, is usually harmful. Alcohol taken by those who are 
devitalized by old age or by disease is advantageous. Youth needs 
no artificial food or nervous sedative. Old age and the man weak- 
ened by illness often needs something which is easily utilized for 
energy to support the system and make life easier. 

Elimination.— Alcohol is rapidly absorbed and rapidly destroyed 
by, or eliminated from, the body. In medicinal doses it is largely 
"burnt up;" but when taken in excess of the body's oxidizing power 
it is eliminated as alcohol by the lungs and by the skin, kidneys 
and intestines. 

Digestion.— Alcohol added in any amount to food in a test-tube 
containing digestive ferments retards or inhibits digestion, but in the 
stomach, on the other hand, when used in moderation, it assists the 
process; for by reason of its irritant and stimulating properties it 
induces the secretion of the digestive juice. This statement has 
been proved correct by Kast, who gave alcohol to a human being 
with gastric fistula. Further than this, the presence of alcohol in 
moderate amount in the stomach aids absorption by stimulating the 
mucous membrane. When excessive amounts are ingested it dis- 
orders digestion by inhibiting the action of the digestive ferments. 



ALCOHOL 81 

Therapeutics.— The chief use of alcohol is as a provider of energy 
and as a rapidly acting equalizer of the circulation in all forms of 
circulatory failure with feebleness due to low fevers and prolonged 
wasting diseases, in old age, and in convalescence from acute disease. 
In both croupous and catarrhal pneumonia, when these affections 
occur in alcoholics (see Pneumonia, Part IV), alcohol is useful. In 
pneumonia, in one accustomed to its free use, it is often essential. 

Some additional conditions, to state them specifically, in which 
alcohol is indicated are fainting, sepsis and excessive wasting due to 
prolonged suppuration. It is also useful in many cases of sepsis 
combined with quinine and iron. 

Alcohol should never be given in the presence of circulatory excite- 
ment, but whenever the circulation fails during the progress of a 
chronic disease it is useful. In the catarrhal pneumonia of children, 
brandy or whisky is very useful in the dose of 5 to 60 minims (0.3-4) 
every two hours in a little water or milk when the circulation seems 
feeble. (See Administration.) In exhausting fevers, such as typhoid 
or typhus, alcohol finds its true usefulness. While it may be needful 
to give alcohol in some cases of enteric fever from the beginning to 
the end of the attack, for the double purpose of aiding digestion and 
of supporting the system, its administration should not be a mere 
matter of routine, but should be based upon clear ideas of the indi- 
cations it is calculated to fulfil. If the pulse is weak and the patient 
seems to be sinking, or the appetite is failing and adynamia is a press- 
ing symptom, alcohol is indicated; but if the pulse is good, and the 
passage of the patient through his illness is not a stormy one, alcohol 
should be excluded from the sick-room. Sometimes ordinary whisky 
or brandy will in severe typhoid fever disorder the stomach. The 
physician should then employ an old brandy or wine whichMias 
acquired by age an aroma which is called a "bouquet." 

In persistent vomiting the use of small doses of good brandy poured 
on cracked ice will often do much good. 

Alcohol is not only of service internally, but is also useful exter- 
nally as a wash or evaporating lotion over bruises, inflamed joints and 
wounds of a contused character. It acts as a cooling and antiseptic 
dressing. When used for its influence as a local antiseptic it acts 
best in the strength of 60 to 70 per cent, by volume, as the presence 
of the 30 or 40 per cent, of water, by softening the bacterial envelope, 
enables the alcohol to destroy the germ. Pure alcohol is therefore 
much less serviceable than the dilute form. Alcohol is also useful 
for washing the skin of invalids, and "salt and whisky" applied by 
rubbing is an excellent mixture to stimulate the skin of unhealthy 
persons. 

Acute Poisoning. — In acute poisoning a tablespoonful of vinegar will 

often produce remarkable effects in restoring consciousness. How it 

acts is now known. In advanced poisoning by alcohol, with coma 

and total relaxation, external heat and hypodermic injections of 

6 



82 DRUGS 

digitalis and strychnine are indicated if the heart or respiration seems 
to be failing. Atropine should be administered to stimulate the 
vasomotor system if the skin is relaxed and clammy, and counter- 
irritation to the back of the neck is to be employed if any brain 
symptoms are present. The after-treatment consists in the use of 
substances stimulating to the stomach, such as ammonia, spirit of 
Mindererus, and spices, unless there is gastric inflammation, when 
emollient substances should be used to quiet the irritation. If 
persistent vomiting comes on, it must be quieted by the patient 
swallowing pieces of ice, or by minute doses of ipecac. Counter- 
irritation should be applied over the belly. If the emunctories are 
not acting freely, thorough purgation by jalap or elaterium (40 
grains [2.6] of jalap powder or J grain [0.008] of elaterium) should be 
employed; or full doses of calomel followed by a saline may be given 
if milder effects are sought. For the morning vomiting of drunkards 
Fowler's solution of arsenic is often a valuable remedy. 

In view of the frequency with which alcoholic and opium poison- 
ing are confused, the following table is appended, which will be 
found of value in making a differential diagnosis as to the condition 
of the patient. 

Alcoholism and Opium Poisoning. 

Alcoholism. Opium Poisoning. 

1. Pupils normal or dilated. 1. Pupils contracted. 

2. Respiration nearly normal. Pulse 2. Respiration and pulse slow and 
rapid, and finally feeble. full. 

3. Face may be pallid. 3. Face suffused and cyanosed. 

4. Skin cool, perhaps moist. 4. Skin warmer than in alcoholic 

poisoning. 

5. Pulse rapid, at first strong, then 5. Pulse slow, strong, and full till 
weak. late in poisoning. 

There is scarcely any difference as to consciousness in the two conditions. 
In medico-legal cases the urine should be preserved in hermetically sealed vessels 
for examination. 

Acute alcoholism and apoplexy are often confused. They are 
differentiated in the following table: 

Acute Alcoholism and Apoplexy. 

Alcoholism. Apoplexy. 

1. Pulse rapid, compressible and weak. 1. Pulse apt to be strong and slow. 

2. Skin moist, or relaxed and cool. 2. Skin hot or dry. 

3. Bodily temperature lowered. 3. Bodily temperature raised. 

4. Pupils equally contracted or dilated ; 4. Pupils unequal, 
generally dilated. 

5. No hemiplegia. 5. Hemiplegia: one side moved, the 

other remaining motionless. 

6. Breathing not so stertorous nor so 6. Respiration stertorous, the lips 
one-sided in lips. being inflated on one side on expiration. 

7. No facial palsy. 7. Facial palsy. 

8. Unconsciousness may not be com- 8. Unconsciousness complete, 
plete. 

The odor of alcohol in the breath is no guide, as acute alcoholism and the rupture of 
a cerebral bloodvessel may both be present. 



ALCOHOL 83 

The question as to what is an intoxicating dose of alcohol has 
assumed increased importance in the United States under Pro- 
hibition. Much depends upon the form in which it is taken, the 
rapidity with which it is ingested, the state of the digestive organs 
as to activity and the presence of food and other drink, upon whether 
the individual is by idiosyncrasy susceptible or insusceptible to its 
effects and whether he is able to take it freely because he has trained 
his system to rapidly oxidize it. So, too, larger amounts may be 
taken if hard physical exertion is being carried on than if the patient 
is at rest. Taken in concentrated form it is obviously more severe 
in its effects than if the alcohol is well diluted, which in part explains 
the difference in the intoxicating effects of whisky and brandy on 
the one hand and beer on the other. Further, when taken well 
diluted, it is not only more slowly absorbed, but time is given for it 
to be oxidized or excreted before enough is present in the blood 
stream to produce intoxication. 

According to the experiments of Schweisheimer, men in repose on 
a couch ingesting to the full capacity of their stomach a volume of 
red wine containing 10.35 per cent, of alcohol by volume show the 
conditions generally recognized as intoxication or drunkenness when 
the alcohol content of the blood reaches a percentage of from 0.134 
per cent, to 0.153 per cent, by volume. 

Marshall in two experiments with men who, in repose on a couch 
during the experiment, had each ingested within a period of ten 
minutes 1200 cc (the full capacity of their stomach) of beer contain- 
ing 2.75 per cent, by weight of alcohol (equivalent to 3.49 per cent, 
by volume) and at intervals of one hour determining the quantity of 
alcohol in the blood, found that the maximum quantity of alcohol 
in the blood of one man was reached at the end of the first hour 
after the ingestion of the beer and amounted to 0.035 per cent, by 
volume, and in the other case at the end of the second hour after 
the ingestion of the beer amounted to 0.0325 per cent, by volume. 
In a third experiment with a man not in repose, but engaged in his 
everyday activities, who had ingested 1200 cc (the full capacity of 
his stomach) of beer containing 2.75 per cent, by weight of alcohol 
(equivalent to 3.49 per cent, by volume) and at intervals of one 
hour (except in the first period which was forty-five minutes) deter- 
mining the quantity of alcohol in the blood, found that the maximum 
quantity of alcohol in the blood was reached at the expiration of 
forty-five minutes after the ingestion of the beer and amounted to 
0.015 per cent, by volume. 

The quantities of alcohol in the blood in all three cases were far 
below the quantities established by Schweisheimer as necessary to 
produce intoxication. 

The men upon whom the experiments were performed were aged 
between twenty-two and twenty-three years and were infrequent 
drinkers of alcoholic beverages. In no case did the subject experi- 



84 DRUGS 

ence nausea or dizziness, and their mental faculties were perfectly 
clear throughout the experiment. Nor was there any unsteadiness 
of gait in walking. 

The lethal dose of whisky is not determined. A few ounces may 
kill a child, whereas it is not uncommon for Polish laborers in this 
country to take as much as 2 or 3 quarts of whisky in a day without 
producing a condition approaching death. 

Chronic Poisoning of the Alcoholic Habit.— Chronic poisoning by 
alcohol results in very characteristic changes in the tissues. As the 
liver receives the alcohol from the stomach diluted only by the portal 
blood, it is often affected very early, and cirrhosis of this organ comes 
on with its accompanying gastric and nutritional symptoms. Mental 
disturbances are common, and neuritis may develop and produce 
paralysis or symptoms resembling locomotor ataxia. 1 

Chronic alcoholics can take large amounts of alcohol without 
much immediate effect because of the fact that they develop an 
ability to oxidize the drug which is not possessed by the ordinary 
individual. 

The treatment of chronic alcoholic poisoning may be carried out 
in two ways : First, by the isolation of the patient and the complete 
withdrawal of the drug at once; secondly, by a better plan, a gradual 
tapering-off in the daily amount of the spirit. In either instance 
isolation must be absolute, and all smuggling of alcohol to or by the 
patient prevented. The attendants must be absolutely trustworthy. 
Careful scrutiny of bedclothes and closets will often be rewarded by 
finding hidden whisky bottles. The depression of the patient when 
recovering from alcoholism must be met by the use of nutritious 
broths, highly seasoned in order to stimulate the stomach, by easily 
digested or predigested foods, and by small doses of digitalis or 
strychnine if the patient be very weak and need such a stimulus. 
Koumyss is an exceedingly valuable and nutritious preparation under 
these circumstances. 

In the treatment of the atonic stomach of drunkards a valuable aid 
is to be found in the following pill: 

]$— Oleoresinse capsici Tfl.x (0.6) 

Olei caryophylli 17U (0.6) 

Hydrargyri chloridi mitis gr. xx (1.3) 

Aloes purificatse gr. xl (2.6). — M. . 

Fiant pilulse, No. xx. 

S. — One three times a day after or before meals. 

If this pill fails to move the bowels, a saline purgative may be 
used or 2 or 3 compound cathartic pills be given. 

1 See author's Diagnosis of Disease, 8th edition. Lea & Febiger, Philadelphia. 



ALCOHOL 85 

The following are the principal points in the differential diagnosis of 
Chronic Alcoholism and the General Paralysis of the Insane. 

Chronic Alcoholism. Paretic Dementia. 

1. Attacks shorter, and more widely 1. Attacks more prolonged, 
separated by intervals of sanity. 

2. Delirium may be of any character. 2. Delirium of grandeur more marked 

and defined. 

3. Visions more characteristic, and are 3. Visions often not evil, but pleasant. 
evil. 

4. Tremors confined to head and arms. 4. Tremors more diffused. 

5. Tremors removed by dose of alcohol. 5. Tremors made worse by alcohol. 

6. Mental symptoms temporarily re- 6. Mental state made worse by alco- 
moved, or at any rate improved, by alco- hoi. 

hoi. 

7. Tremors occur chiefly in the morn- 7. Tremors not confined to the morn- 
ing, ing. 

There is danger of pneumonia from failure of the right side of the 
heart in subacute and chronic alcoholism, and the physician should 
always be on the lookout for this complication. 

Administration.— Brandy and whisky are generally used as a means 
of getting alcohol into the body. They should be exhibited in the 
form best adapted to the work they are intended to perform. If the 
action must be instantaneous, as in a case of fainting, they should 
be employed hot and concentrated, so that the stomach has not to 
warm the liquid before absorption. They are to be used hypoder- 
mically if still more rapid action is required. If administered to aid 
digestion and support the system, then they should always be given 
with the food— never alone, and never concentrated. They may be 
given as milk-punch or as eggnogg, the latter being the "heavier" 
of the two so far as digestion is concerned. In fevers of a typhoid 
type the dose of whisky or brandy may be for an adult from § to 2 
ounces (15.0-60.0) every three or four hours. More than a pint in 
twenty-four hours is rarely required, but this amount often does 
great good and is not excessive if the patient is accustomed to its 
use and needs supporting treatment. When brandy or whisky is 
given to children, the following rules as to dosage may be used as 
indicating the approximate proper dose: 5 to 10 minims (0.3-0.6) 
every four hours for a child one month old; 10 to 20 minims (0.6-1.3) 
for a child two months old; 20 to 30 minims (1.3-2.0) for a child 
three months old; 30 to 40 minims (2.0-2.6) for a child over three 
months old; 60 minims (4.0) for a child over four months old. In 
some cases, however, it is well to use half these doses every two 
hours. In all cases the liquor should be diluted with warm or cool 
water. Wine- whey is very light and useful. Mulled wine and 
champagne are particularly useful in the treatment of irritable 
stomach. When milk punch is used care should be taken to shake 
the whisky and milk together before administering the mixture. 
Milk punch made with Jamaica rum is often useful. (See Foods for 



86 DRUGS 

the Sick.) Champagne when used as a medicinal substance should 
always be as devoid of sugar as possible— that is, what is known as 
"extra dry" or "Brut." Gin is rarely employed as a stimulant, 
except when the kidneys are torpid. Stout and porter are of value 
in wasting disease, in convalescence from acute diseases, and for 
nursing women. Beer also may be so used and often acts as a tonic 
and appetizer. 

Contraindications.— x\ll states of cerebral excitement, unless due 
to exhaustion, acute inflammations, the alcoholic habit, apoplexy, 
meningitis, acute nephritis, acute gastritis, hepatic congestion or 
inflammation, contraindicate the use of alcohol, as does also the 
history of the alcoholic habit. 

Preparations.— Dilute alcoholJ(.4/co/ioZ Dilutum, U. S.), pure alcohol 
{Alcohol, U. S.), and absolute alcohol {Alcohol Dehydratum, U. S., 
Alcohol Absolution, B. P.) are official. 

The commonly used and not official preparations of alcohol are 
as follows : 

Whisky {Spiritus Frumenti) should be at least four years old, 
and be made, in America, from rye, for medicinal purposes. 

Brandy {Spiritus Vini Gallici) is obtained by the distillation of 
fermented grapes or fruits, and should be from three to five years 
old before use. 

Cologne- water {Spiritus Odoratus) is used solely as a lotion and 
perfume. 

Red wine is made from grapes not deprived of their skins. White 
wine is the fermented juice of grapes the skins of which have been 
removed. 

Rum is made from the fermentation of molasses, and contains 
about 40 to 45 per cent, of alcohol. 

Gin is made from rye or barley, with the addition of juniper ber- 
ries and hops. (Good "rye" gin and the Spiritus Juniperi Composi- 
tus of the U. S. P. are virtually identical therapeutically.) When 
diuresis is required and atony of the kidneys is present, without 
inflammation, gin is a useful medicament, provided that alcohol 
is indicated. Gin is one of the alcoholic drinks most apt to produce 
cirrhosis of the liver. 

Port Wine {Vinum Portense) is a fermented wine, to which pure 
spirit is added to increase its strength. It is one of the strongest 
table wines, and is useful as a supportant in convalescence. 

Sherry {Vinum Xericum) has about 30 per cent, of alcohol in it. 

Beer is made by a slow fermentation, while ale is made by a more 
rapid fermentation at a higher heat. Most of the beer in America 
contained about 4-6 per cent, of alcohol before prohibition laws 
were passed. 

Porter resembles the other malt liquors closely, except that it 
contains more solids, due to a scorching of the grain by a high heat. 

The B. P. preparations that are not official in the U. S. P. are 



ALMONDS 87 

rectified spirit (Spiritus Bectificatus) and sherry (Vinum Xericum). 
Mistura Spiritus Vini Gallici is a useful, pleasant and nutritious 
stimulant made by beating up the yolks of two eggs with half an 
ounce of sugar, and then adding four ounces each of brandy and 
cinnamon- water. This is sometimes called "egg-flip." Dose 1 to 
2 ounces (30.0-60.0). 

ALLIUM. 

Garlic, or Allium Sativum, is a stimulant to digestion, owing to 
the volatile oil it contains, which by its somewhat irritating proper- 
ties excites the gastric mucous membrane to increased secretion. In 
persistent colds, where the bronchial tubes are particularly affected, 
a garlic poultice made by pounding the bulbs in a mortar, is a very 
efficient though disagreeable remedy. If the skin is too delicate to 
permit of the use of pounded garlic alone, it may be mixed with equal 
parts of bran, and a poultice or plaster made thereof. Employed 
in this form, allium is useful if applied over the spine or feet in the 
treatment of the cerebral and spinal convulsions of infants; placed 
over the belly in cases of g astro-intestinal catarrh, it acts almost as 
well as a spice poultice. In the treatment of children with chronic 
colds garlic may be used boiled in milk, and the liquid given as a 
drink, warm or cold; or the oil of garlic may be given in emulsion 
in the dose of 1 or 2 minims (0.05-0.1). It ought not to be given 
during the febrile stage, as it is stimulating. Allium juice has also 
been used in the dose of 2 to 5 drops (0.1-0.3) to relieve nervous 
vomiting. The dose of the syrup (Syrupus Alii) for a child is 1 
dram (4.0), but 4 drams (16.0) may be given to an adult. 

ALMONDS. 

Almonds are official in the form of the sweet almond (Amygdala 
Dulcis, U. S. and B. P.). Bitter almonds develop hydrocyanic acid 
in the presence of water by the reaction between the amygdalin 
and water in the presence of the emulsin contained in them; this 
is not the case with sweet almonds. 

Sweet almonds, when rubbed up in a mortar with water, form a 
pleasant-tasting emulsion of an greeable odor that is very useful as a 
vehicle for remedies having a disagreeable taste. Almond bread has 
been proposed as a food for diabetics, owing to its containing virtually 
no starch; but it is requisite that the oils and saccharine constituents 
of the almond shall first be removed. (See Foods for the Sick.) 

When half an ounce of sweet almonds are rubbed up with 30 grains 
of gum arabic and 2 drams of sugar, to which is added gradually a 
half-pint of distilled water, the mixture being then strained, an emollient 
and soothing drink is formed, which is very useful in irritations of 
the stomach and intestines and of the air-passages and pharynx. The 
expressed or fixed oil of almonds is a useful demulcent, and has been 



88 DRUGS 

recommended in the cough of phthisis, given in the dose of a J dram 
(2.0) in emulsion. 

Bittler almonds yield an oil {Oleum Amygdala Amarce, U. S.) which 
is exceedingly poisonous owing to the prussic acid which it contains, 
and it is said that one drop will kill a cat, while seventeen drops have 
killed a man. Oil of bitter almond should contain from 2 to 4 per 
cent, of hydrocyanic acid. 

Bitter almonds have been used to allay irritable coughs and similar 
states, but are not frequently employed because other drugs are less 
dangerous, more stable, and more active as remedial agents. The 
emulsion of bitter almonds is made as is that of sweet almonds, and 
may be used in teaspoonful doses for the same purposes and as a 
vehicle in cough mixtures. Both emulsions are useful as vehicles in 
the treatment of gonorrhea, as they diminish the burning on urination. 
Almond emulsions, when locally applied, are supposed to be of value 
for the removal of freckles and sunburn. 

The preparations of sweet almonds are: an emulsion (Emulsum 
Amygdala, U. S., and Mistura Amygdala, B. P.), dose 1 to 2 ounces 
(30.0-60.0); a compound powder (Pulvis Amygdala Compositus, B. 
P.), given in the dose of 1 to 2 drams (4.0-8.0); and the oil (Oleum 
Amygdala Expressum, U. S., and Oleum Amygdala, B. P.), the dose 
of which is 1 to 4 drams (4.0-16.0). Aqua Amygdala Amara (U. 
S.) is prepared from the oil of bitter almonds. The dose is 60 to 
120 minims (4.0-8.0). 

ALOES. 

Aloes, or Aloe of the U. S. P., is the inspissated juice of the leaves 
of Aloe Vera (Linne) Webb, Aloe Chinensis Baker, Aloe Perryi 
Baker, or other species of Aloe (Fam. Liliacea). It occurs in yel- 
lowish-brown or orange-brown to blackish-brown opaque masses; 
translucent in thin fragments; fracture uneven, dull and waxy, some- 
what resinous, or smooth and glassy, somewhat conchoidal; occa- 
sionally exhibiting microscopic crystals of aloin; odor characteristic; 
taste nauseous, bitter. It is also probably derived from several other 
species than those just named. Aloes contains an active principle 
known as aloin (Aloinum, U. S. and B. P.), which is a crystalline 
substance. As generally sold, aloin is, however, an amorphous 
powder of extremely bitter taste. 

Physiological Action.— Locally applied to the tongue, aloes is a 
bitter of rather a persistent taste. According to the studies of 
Rutherford, the drug increases very considerably the flow of bile 
in the dog, but in man it cannot in any sense be regarded as a medica- 
ment for the production of an increased biliary flow. Rutherford's 
doses given to the dog amounted to as much as 60 grains, equal to 
3 or 4 drams in a man. In the lower animals and in man aloes acts 
very slowly, requiring several hours for its influence to be manifested 
unless the dose be toxic in amount. Its chief influence is on the 



ALOES 



89 



lower bowel (Fig. 6), although Pfaff and Nelson assert that it also 
acts upon the stomach and upper bowel. As much as 4 drams of 
aloes have been injected into the veins of a horse without inducing 
purgation, probably because 4 drams were not enough to affect the 
bowels of this animal. It is eliminated in the milk of nursing women, 
and will cause purgation in an infant put to the breast of a patient 
taking it. If the doses be quite large (10 to 20 grains), the passages 
will be water; but if the dose be more moderate (2 or 3 grains), the 
stools will be thick and pultaceous. 



IUJ(© 




Fig. 6. — A, chief effect of aloes is exercised in lower bowel or cok 



Therapeutics. —Aloes should be used only when a somewhat slow 
stimulant to peristaltic movement is desired, and never where the 
object of the physician is to relieve congestions by depletion through 
the intestine. It is a favorite remedy in cases of subacute or chronic 
constipation, but it is distinctly harmful if continued for any length 
of time, as it seems to produce atony of the bowel. Owing to its 
bitter- properties it acts as a tonic to the stomach, and is often given 
with iron, as clinical experience indicates that their conjoint use is 
beneficial. Its good effects depend upon its preventing the consti- 
pation which might be produced by the chalybeate. 

When taken in a sufficiently large dose to produce a copious pas- 
sage, aloes nearly always produces a feeling of weight and fulness in 
the region of the rectum after the evacuation, and the writer has 
seen severe rectal catarrh produced in this way in very susceptible 
persons. If given alone, it is very apt to produce griping, and it 
ought always to be combined with other drugs whose tendency is to 
prevent intestinal spasm. 

In cases of hemorrhoids in individuals suffering from general 
muscular relaxation and atony, aloes is said to do great good, but its 



90 DRUGS 

use under these circumstances is by no means universal or generally 
accepted as correct. For weak, anemic persons leading sedentary 
lives it may be combined with tonics to relieve the constipation so 
often an urgent symptom in these cases. In amenorrhea dependent 
upon atony of the sexual system, or anemia, or constipation, it is 
thought to have a specific emmenagogue influence. Locally applied 
in the form of the glycerol of aloes, it has been employed in the 
healing of old or recent fissures of the rectal mucous membrane, and 
even on bed-sores. The glycerole of aloes is to be made by evaporat- 
ing 4 to 8 parts of tincture of aloes and gradually adding 30 parts of 
glycerin. 

Contraindications.— Constipation occurring in plethoric persons 
should not be treated by aloes as they need salines, and it should 
not be used if any irritation or catarrh of the intestine is present. 
Pregnant women should use aloes most carefully lest abortion be 
produced, and if hepatic congestion or inflammation is present it 
ought not to be used. Fever is also said to contraindicate the 
use of aloes, as does also rectal catarrh. 

Administration.— A loes, U. S., is generally given in a pill, com- 
bined with strychnine and belladonna. (See Constipation, Part IV.) 
The dose should be 1 to 5 grains (0.06-0.3) as a laxative, and 10 
grains (0.6) as a purge. The official preparation most commonly 
employed is the pill of aloes (Pilulce Aloes, U. S. and B. P.), 2 grains 
(0.12) each of aloes and soap. The dose is one or two pills. Aloinum 
(U. S.) is given in the dose of \ grain (0.015). The liquid prepara- 
tion is the tincture (Tinctura Aloes, U. S. and B. P.), dose, 1 to 2 
fluidrams (4.0-8.0). The official pills of the B. P. are the Pilula 
Aloes et Asafetidw, Pilula Aloes et Myrrha, and Pilula Aloes et 
Ferri. The other B. P. preparation, besides those given, is the 
Decoctum Aloes Compositum, dose, J to 2 ounces (15.0-60.0). 

ALUM. 

Alum {Alumen, U. S., and Alumen Purificatum, B. P.) is the sul- 
phate of aluminum and potassium in the U. S. P., but in the -B. P. 
both it and the sulphate of aluminum and ammonium crystallized 
from a watery solution are official. At present much of the alum 
of commerce is obtained as a by-product in the manufacture of 
coal-gas for illuminating purposes, and it is therefore very cheap. 
It occurs in the form of octahedral crystals, and has an astringent 
taste and acid reaction. After the crystals are exposed to the air 
for some time they become covered with a white coating. 

Physiological Action.— When alum is brought in contact with a 
mucous membrane it produces whitening, constriction and puckering 
of the part, and applied to the skin thickens and hardens it by 
means of its astringent action. In either case it decreases secretion 
and causes contraction of the local bloodvessels and capillaries. 



ALUM 91 

Large amounts given internally for any length of time seem to 
increase secretion. 

Poisoning.— Very large amounts are necessary to produce death. 
As much as 2 ounces will not kill a sickly dog. This is largely due 
to the fact that the vomiting and purging rid the animal of the drug, 
for if vomiting is prevented death rapidly ensues from gastro-enteritis. 
Injected into the blood, alum produces embolism and thrombosis. 

Therapeutics.— Alum is used at present in a number of diseases, 
chiefly as a local application. In cases of ordinary sore-throat appli- 
cations of a strong solution (20 grains to the ounce of water— 1.3- 
30.0) on a swab are very useful. It would be of much service in this 
condition as a gargle were it not that it possesses a destructive action 
on the teeth. In hemorrhage, when the leaking bloodvessels can be 
directly reached, alum is a powerful hemostatic, aiding in the arrest of 
the bleeding in three ways— namely, by coagulating the albumin, by 
constringing the parts, and by crystallizing when applied in large 
amounts on lint, and thereby affording a surface which is rough 
and aids coagulation. In hemorrhage after tooth-extraction its appli- 
cation is a very useful treatment. Dissolved in water or alcohol, 2 
grains to the ounce (0.1-30.0), it makes an exceedingly efficient appli- 
cation for sponging in night-sweats or localized sweating of the feet or 
hands. Used in weak solution in an atomizer it may be resorted to 
in bronchorrhea or chronic bronchitis with excessive secretion, and in 
chronic catarrh of the pharynx. In mercurial ptyalism a solution of 
the drug may be used on a swab. Bathing with an alum solution 
the parts affected is said to be an efficient remedy in chilblains, and 
for pruritus vulva?. As a vaginal wash for profuse leucorrhea, in the 
strength of from 10 to 20 grains to the ounce (0.65-1.3 to 30.0) of 
water, alum is of value. Some observers claim good results from its 
use in diphtheria and tonsillitis. In follicular tonsillitis the alum- 
stick may be deeply inserted into the depressed follicles or applied 
to the swollen surface of the gland. In ingrowing toe-nail with granu- 
lations a piece of twisted absorbent cotton soaked in strong alum 
solution and inserted under the edge of the nail in most instances 
produces a cure. A popular solution in the dressing of contused 
wounds called "Alum-Acetate Solution" is composed of: 

1^— Alumini . 3ss (2.0) 

Plumbi acetatis 3j (4.0) 

Aquae destillatse f§iv (120.0) 

Dried alum (Alumen Exsiccatum, U. S. and B. P.) is useful as a 
dressing for old ulcers and sores, and has been highly recommended 
as an application for swollen gums where they press upon and over- 
ride a tooth, particularly at the back of the jaw. The possibility of 
its exercising an evil effect on the teeth should not be forgotten. 

In the proportion of 1 tablespoonful (15.0) of powdered alum to 1 
quart (1 liter) of warm water this drug is often efficient when used 
as a rectal injection in post-operative tympanites and similar states. 



92 DRUGS 

Alum may be used as an antidote in acute lead-poisoning, as it is 
a soluble sulphate and also an emetic. 

The emetic dose of powdered alum is a heaping teaspoonful for a 
child or a tablespoonful for an adult. 

Glycerinum Aluminis (1 to 6) is official in the B. P., and is used 
as a local astringent application. 

ALUMINUM ACETATE. 

Aluminum acetate (Alumini Acetas) is a useful astringent appli- 
cation in erysipelas, rhus poisoning, boils and carbuncles in their 
formative stage, and septic infections of the hand and arm or foot 
and leg. The solution employed is the Liquor Alumini Acetatis of 
the National Formulary diluted in the porportion of 1 to 7. 

ALYPIN. 

Alypin is used as a local anesthetic and appears in the form of a 
white crystalline powder, readily soluble in water and in alcohol, the 
solution being neutral in reaction. It is a glycerine derivative, tech- 
nically called the monohydrochloride of benzoyl. Solutions of it can 
be sterilized by boiling, provided the heating does not extend beyond 
five minutes. It is claimed to be equal in power to cocaine for the 
production of anesthesia, and is commonly employed in freshly pre- 
pared 2 per cent, solution in the eye and in 10 per cent, solution on 
other parts. When dropped into the eye it is said not to cause 
mydriasis nor affect accommodation. It does not constrict local 
bloodvessels, which is advantageous in some cases and disadvantag- 
eous in others; thus, in operations upon engorged nasal mucous 
membranes it fails to open the field of operation. The secondary 
congestion so characteristic of cocaine is said to occur in an exagger- 
ated form after the anesthetic effect of alypin. Solutions of alypin, 
with or without adrenalin, may be employed for infiltration anesthesia 
by Schleich's method. Alypin is less irritating than eucaine when 
dropped in the eye. (See Cocaine.) 

AMBER. 

Succinum is derived from a fossil resin found in Prussia and in 
Bohemia, and is used in the form of the oil (Oleum Succini), which is 
volatile, quite irritant, and obtained by destructive distillation from 
the deposit named. 

Therapeutics.— Oil of Amber is one of the best remedies for per- 
sistent hiccough that we have. It is very useful as a counterirritant 
over rheumatic joints, and has been used in asthma, whooping-cough, 
and hysteria with good results. In the bronchitis of infants, with 
nervous disturbance, oil of amber in the proportion of 1 to 3 parts 



AMMONIA 93 

of olive oil applied to the back and front of the chest is of service. 
In adults suffering from acute laryngitis with extension of the inflam- 
mation into the bronchial tubes, full doses of sodium bromide given 
internally, with this proportion of amber oil and olive oil rubbed 
into the neck and chest, are useful. The dose internally is 2 to 6 
minims (0.1-0.4) given in emulsion. 



AMMONIA (NH 3 ). 

Ammonia is a gas of a very acrid, burning taste, capable of pro- 
ducing death very rapidly when inhaled, by reason of the inflam- 
mation of the air-passages and the spasm of the glottis which ensue. 
It is made in large amounts in the manufacture of coal-gas. 

Physiological Action.— When ammonia comes in contact with the 
tissues of the body it acts as a most powerful irritant, causing a red- 
dening of the parts, followed, if the exposure be sufficiently pro- 
longed, by local death and sloughing. If it be inhaled as a gas, it 
may produce rapid death by spasm or edema of the glottis, and 
if a strong solution of it is swallowed, the same accident may occur. 
Following more moderate inhalations severe bronchitis or pulmonary 
edema may develop. 

Nervous System.— If ammonia be injected into the blood of 
animals, violent convulsions at once ensue which are largely tetanic 
in type and depend upon a spinal action of the drug, since they 
are not stopped by division of the spinal cord, as they would be if 
the convulsive movements had their origin in the brain. The drug 
in moderate amounts acts as a spinal excitant, increasing reflex 
action and all the evidences of spinal activity. If applied directly 
to a nerve, either motor or sensory, it paralyzes the nerve; but if 
the drug be in a very weak solution, it seems to increase the functional 
activity of the nerve. 

Circulation.— Upon the circulation ammonia acts as a powerful 
but fleeting stimulant, increasing the pulse-rate, pulse-force, and 
arterial pressure. The cause of the increased pulse-rate depends 
upon stimulation of the accelerator nerves of the heart and of the 
heart itself, while the increase in force is due to the same cause, for 
Ringer 'and Sainsbury found the strength of the ventricles much 
increased. The rise of arterial pressure is due to the increased 
amount of blood pumped into the arteries by the stimulated heart, 
and probably by a stimulant action on the vasomotor center, although 
this is denied by some authorities. As the drug acts as a stimulant 
on the respiratory center, which is very near the vasomotor center, 
it probably increases the functional activity of both. If by means 
of intravenous injection the ammonia reaches the heart in large 
amount in concentrated form, this organ ceases to beat at once, 
owing to paralysis of its muscular walls. 



94 



DRUGS 



-D 



The Blood.— In moderate amounts the drug has no effect on the 
blood, but when injected in poisonous quantities it causes the blood 
to fail to take up the oxygen, according to Feltz and Ritter. 

Respiration.— The injection of ammonia in moderate quantities 
into the blood causes an acceleration of the rate of respiration due to 
stimulation of the respiratory center, the respiratory movements 
becoming not only more full, but also more rapid. If the drug is 
inhaled in small amounts or swallowed, the same action is seen in 
a less degree, the changes both in breathing and circulation being 
partly due under such circumstances to a reflex irritation transmitted 
along the sensory nerves. 

Elimination.— Ammonia when taken into the body is so extremely 
fleeting in its action that the question as to its escape from the sys- 
tem is of interest. If large amounts 
are taken, it is partly given off 
by the breath, but more of it is 
destroyed in the system, and ac- 
cording to Bence Jones, eliminated 
as nitric acid by reason of its being 
oxidized in the body. The greater 
part, however, is excreted as urea. 
Therapeutics.— Ammonia is em- 
ployed for four distinct purposes in 
medicine— namely, as a circula- 
tory and respiratory stimulant, as 
a counterirritant, and as an antacid. 
The indications for the use of 
ammonia in the first class of cases 
are all forms of sudden cardiac 
failure where there is no time or 
opportunity to use the more stable 
and slowly acting drugs. These 
emergencies occur in snake poison- 
ing, in syncope from fright or other 
shock, or from indigestion, in sudden 
cardiac failure during the course 
of fevers and in pneumonia, and in all cases where prompt cardiac 
stimulation is needed. In the most pressing cases it should be 
injected directly into a vein of the leg, so as to act more quickly. If 
put into the subcutaneous tissues, it is almost certain to cause a 
slough, and if injected into a vein of the arm, it may reach the heart 
in too concentrated form and cause cardiac depression. Ringer has 
found that the drug has the extraordinary power of causing a heart 
stopped or depressed by chloroform to resume its beating. It is 
claimed, without much justification, that ammonia will aid in pre- 
venting heart-clot or thrombosis in cases of severe hemorrhage and in 
pneumonia. 




Fig. 7. — Ammonia stimulates: A, 
the accelerator nerves; B, the heart- 
muscle itself, and so quickens pulse- 
rate and force. It stimulates the vaso- 
motor center C and the respiratory 
center D. 



AMMONIUM 95 

In prolonged diseases the employment of ammonia is not particu- 
larly advisable, owing to its fugacious action, although it is largely 
used, for the frequent administration necessarily required is apt to 
produce gastric disorder. Some writers claim that ammonia is useful 
as a sedative in drunkenness, but this is doubtful. 

In gastric acidity due to fermentation, with the development of 
abnormal acids, ammonia is the most active remedy we can employ, 
but it is not to be given if acute irritation of the stomach exists. 

Locally applied, strong ammonia-water may be used to produce a 
blister by placing a few drops on the skin under an inverted watch- 
glass. Ammonia-water may also be applied, often with great relief, 
to the spots stung by insects. The waters of ammonia are used exter- 
nally in stimulating liniments, and hypodermically when the drug is 
so given. The stronger water ought not to be employed for the latter 
purpose. The aromatic spirit is generally used internally in the dose 
of \ dram to 1 dram (2.0-4.0), well diluted. This is also the dose of 
the ordinary spirit. 

Administration.— Ammonia is never employed in medicine as pure 
ammonia gas, but in the form of the stronger water (Aqua Ammonia? 
Fortior, U. S., Liquor Ammonice Fortis, B. P.), containing not less 
than 27 per cent, nor more than 29 per cent. (32.5 per cent., B. P.), 
by weight of the gas, and the weaker water (Aqua Ammonia?, U. S., 
Liquor Ammonice, B. P.), which should contain not less than 9.5 per 
cent, nor more than 10.5 per cent, by weight of the gas. The aro- 
matic spirit of ammonia (Spiritus Ammonia 3 Aromaticus, U. S. and 
B. P.) is given in the dose of 30 to 60 minims (2.0-4.0) in water. 
The latter preparation is composed of carbonate of ammonium, the 
oils of nutmeg, lemon, and lavender, with alcohol and ammonia- 
water. Spiritus Ammonice Fcetidus (B. P.) contains asafcetida, and 
is used in place of the aromatic spirit. Ammonia liniment (Lini- 
mentum Ammonia 3 , U. S. and B. P.) is used over tender joints and 
muscles. 

AMMONIAC. 

Ammoniac (Ammoniacum, B. P.) is a resinous gum obtained from 
Dorema Ammoniacum, and is little used in medicine at the present 
time. Internally and externally it produces some irritation when 
brought in contact with the tissues, and may be used internally in 
the dose of 10 to 30 grains (0.6-2.0) in pills in cases of chronic bron- 
chitis devoid of any active inflammatory process. Mistura Ammon- 
iaci (B. P.) is used in chronic bronchitis in the dose of from J to 1 
fluidounce (15.0-30.0). 

AMMONIUM (NH4). 

The following salts of ammonium are official, and are used for 
various purposes: 



96 DRUGS 



Acetate of Ammonium. 

Acetate of Ammonium is used in medicine in the form of the 
spirit of Mindererus (Liquor Ammonii Acetatis, U. S. and B. P.), 
dose 1 to 2 fluidrams (4.0-8.0), 2 to 6 fluidrams (8.0-24.0), B. P., 
for the purpose of acting as an antacid in gastric indigestion, and 
also as a mild diuretic and diaphoretic which is inferior to sweet 
spirit of nitre. 

Benzoate of Ammonium. 

Benzoate of Ammonium (Ammonii Benzoas, U. S. and B. P.), 
should contain not less than 98 per cent, of pure Ammonia Benzoate 
(C 6 H5.COONH 4 ), and should be kept in well-stoppered bottles. 

It occurs in thin, white, laminar crystals or a crystalline powder; 
odorless or having a slight odor of benzoic acid, a saline, bitter, after- 
ward slightly acrid taste, and gradually losing ammonia on exposure 
to the air. One gram is soluble in about 10 cc of water and 35.5 
parts of alcohol and about 8 cc of glycerin at 25° C. (77° F.). 

It is employed chiefly for its diuretic influences, which depend 
entirely upon the benzoic acid present in the compound. As benzoic 
acid is eliminated as hippuric acid and ammonia as nitric acid, this 
drug may be employed in cases where the physician desires to make 
the urine decidedly acid; as, for example, in patients suffering from 
catarrh of the bladder, when the urine is loaded with phosphates, 
which are dissolved by this acidulation. It is useful in certain cases 
of muscular rheumatism. The dose is 10 to 30 grains (0.6-2.0), 
which should be suspended in water or, better, administered in 
cachets or capsules. 

Bromide of Ammonium. 

Bromide of Ammonium (Ammonii Bromidum, U. S. and B. P.), 
should contain not less than 98.5 per cent, of pure Ammonium 
Bromide, and should be kept in well-stoppered bottles. 

It occurs as colorless, transparent, prismatic crystals, or a white, 
crystalline powder; odorless, of a pungent, saline taste, and perma- 
nent in dry air and is soluble in 1.3 parts of water, and in 12 parts 
of alcohol at 25° C. (77° F.), in 0.9 part of boiling water, and in 1.2 
parts of boiling alcohol. 

It is, however, generally found in commerce as a white granular 
powder, which, when exposed to the atmosphere, becomes slightly 
yellowish. 

Physiological Action.— Applied to the mucous membrane of the 
mouth, bromide of ammonium produces a salty taste, is markedly 
pungent, and dissolves readily in the oral secretions. If large 
amounts are swallowed, it causes burning pain in the belly and 
evidences of gastro-enteritis. 



AMMONIUM 97 

Nervous System.— The action of this drug upon this part of the 
body is its most important effect. Given to the lower animals, it 
produces in frogs total loss of reflex activity, preceded, it is said, in 
some cases by tetanic convulsions, although no such motor disturb- 
ances may take place. In a series of studies undertaken by the 
writer to determine the effect of the drug it was found that the spinal 
cord was depressed, both on its motor and sensory sides, while the 
nerves and muscles escaped. These results are in accord with those 
of other investigators, who also found that the nerves are unaffected. 
On the cerebral cortex it acts as a distinct sedative. (See Bromide 
of Potassium.) 

Circulation.— Upon the circulation bromide of ammonium acts 
as a stimulant in small doses, but as a cardiac paralyzant if a large 
amount comes in contact with the heart. In medicinal dose it is 
distinctly stimulant to the circulation, but not sufficiently so to 
render it valuable as a circulatory stimulant, to the exclusion of 
other more powerful preparations. 

Therapeutics.— The bromide of ammonium may be used in nearly 
every instance where bromide of potassium may be employed, and 
possesses the distinct advantage of being less depressant to the gen- 
eral system than the latter drug. It is, however, more apt to dis- 
order the stomach even if given in moderate doses. In epilepsy it 
would seem to be of as much value as the potassium salt, and may 
be combined with it in some cases with success. (See article on 
Epilepsy, Part IV.) According to J. M. DaCosta, the drug is of 
distinct value in rheumatism in the dose of 60 to 80 grains (4.0-5.3) 
a day, well diluted with water, although its manner of action in this 
disease is not known. The usual dose is 10 to 30 grains (0.6-2.0). 
It is incompatible with spirit of nitrous ether. 

Ammonium Carbonate. 

Ammonium Carbonate (Ammonii Carbonas, U. S. and B. P.), 
should contain not less than 97 per cent, of a mixture of Acid Ammo- 
nium Carbonate and Ammonium Carbamate and should yield not 
less than 30 per cent, of ammonia gas. It should be kept in well- 
stoppered bottles, in a cool place. For dispensing purposes, only 
the translucent portions should be used. 

It occurs in white, hard, translucent, striated masses, having a 
strong odor of ammonia without empyreuma and a sharp saline taste. 
On exposure to the air, the salt loses both ammonia and carbon 
dioxide, becoming opaque, and is finally converted into friable, 
porous lumps or a white powder. 

It is slowly but completely soluble in about 4 parts of water at 25° 
C. (77° F.), and is decomposed by hot water, with the elimination 
of carbon dioxide and ammonia. By prolonged boiling with water, 
the salt is completely volatilized. 
7 . 



98 DRUGS 

It undoubtedly has an action exactly like that of the liquid prepa- 
ration of ammonia, and is used either alone or with the chloride in 
the treatment of bronchitis, particularly when this disease occurs in 
babies and young children. Ammonium carbonate is also largely 
employed by surgeons in the treatment of children after a surgical 
operation to overcome the respiratory and circulatory depression pro- 
duced by the anesthetic. The dose is 2 to 10 grains (0.12-0.6) in 
syrup of acacia and water. It is a rapidly acting cardiac and respi- 
ratory stimulant. 

1$ — Ammonii carbonatis gr. xlviij (3.2) 

Syrupi acaciae f3 (30.0) 

Aquae destillatae q. s. ad giij (90.0). — M. 

S. — Teaspoonful (4.0) every two hours in water for a child of three or four years. 

Ammonium Chloride. 

Ammonium Chloride or Muriate (Ammonii Chloridum, U. S. and 
B. P.). It should contain not less than 99.5 per cent, of pure Ammo- 
nium Chloride. It occurs as a white, crystalline powder, without 
odor, having a cooling, saline taste, and is somewhat hygroscopic. 
It is soluble in 2.6 parts of water, in 100 parts of alcohol, and in 8 
parts of glycerin, at 25° C. (77° F.), and in 1.4 parts of boiling water. 
The aqueous solution of the salt (1 in 20) in ice-cold water, should 
not redden blue litmus paper at once; it affords, with silver nitrate 
a white, sandy precipitate, which is soluble in ammonia water. 

Ammonium chloride has an entirely different action and therapeu- 
tic use from the rest of this group. It possesses almost no influence 
over the heart and respiration, but does exercise a very stimulant 
effect on mucous membranes, increasing the secretion pf mucus. 
The consideration of its use in diseases of the lungs can be found in 
the articles on Pneumonia and Bronchitis. Chloride of ammonium 
fumes can be obtained from a few grains of the drug heated in an 
iron spoon over a gas-jet or by means of a set of three wash-bottles. 
In one of these is placed stronger water of ammonia, in another 
hydrochloric acid. Each of these is connected with a third bottle 
by means of glass tubing, this bottle being partly filled with water, 
through which the fumes in passing become purified and form the 
fumes of chloride of ammonium. The drug may also be used in a 
spray from an atomizer. Where it is desirable to maintain the 
effect of the drug over a long period of time, as in chronic bronchitis, 
the following method may be followed, as recommended by Mew: 
A soup-plate is placed upon the floor of the room, and from 3 to 4 
ounces (90.0-120.0) of sulphuric acid are placed in it. Into a neigh- 
boring saucer are poured 2 ounces (60.0) of strong ammonia, and 
then about a tablespoonful (15.0) of ordinary table salt is sprinkled 
upon the acid. In less than a minute the room becomes filled with 
dense fumes of nascent chloride of ammonium, which can be readily 
maintained by renewed charging of the soup-plate and saucer. In 



AMMONIUM 99 

this way the patient may be made to inhale chloride of ammonium 
fumes for a long period of time with very advantageous results. 
This is a particularly useful method in cases of fetid bronchitis. 

Chloride of ammonium has been employed in intermittent fever, 
but has gone out of use, and has also been used in neuralgias of the 
ovarian type by Goodell and others. In the treatment of chronic 
torpor of the liver and subacute hepatitis, and even in cirrhosis and 
hepatic abscess, it has been thought of value. Many clinicians have 
found it useful in the treatment of the gastric and intestinal catarrhs 
of children of a very subacute type, and it is the routine treatment 
for all such cases which come under observation at the hospital and 
elsewhere where the author has charge. The dose is 2 to 15 grains 
(0.12-1.0), preferably given with liquorice and water to mask the 
taste. 

]$ — Ammonii chloridi 5ij (8.0) 

Fluidextracti glycyrrhizse f 5j (30.0) 

Aquae destillatae q. s. ad fgiij (90.0). — M. 

S. — Teaspoonful (4.0) t. i. d. in water after meals for a child of five or ten years. 

The chloride of ammonium may, however, be given in compressed 
tablets to adults, provided a large draught of water or milk is taken 
simultaneously to protect the stomach. (See article on Bronchitis 
for other prescriptions.) 

Gillespie asserts that 10 grains (0.6) of chloride of ammonium 
given half an hour before meals gives extraordinary relief in painful 
dyspepsia due to hyperacidity of the stomach. 

Chloride of ammonium, in a lotion of the strength of 1 ounce 
(30.0) to 3 quarts (3 liters) of water, is an efficient remedy for the 
dermatitis caused by poison-ivy. 

Ammonium Iodide. 

Ammonium Iodide (Ammonii Iodidum, U. S.) should contain not 
less than 99 per cent, of pure Ammonium Iodide, and should be kept 
in small amber-colored, well-stoppered vials, protected from light. 

When deeply colored, the salt should not be dispensed, but it may 
be deprived of free iodine by adding to its concentrated aqueous 
solution sufficient ammonium sulphide to render it colorless, then 
filtering, and evaporating on a water-bath to dryness. It occurs 
in minute, colorless, cubical crystals or a white, granular powder, 
without odor when colorless, but emitting a slight odor of iodine 
when colored, and having a sharp, saline taste. The salt is very 
hygroscopic, and soon becomes yellow or yellowish-brown on expo- 
sure to the air and light, owing to the loss of ammonia and the 
liberation of iodine. It is soluble in 0.6 part of water, and in 3.7 
parts of alcohol at 25° C. (77° F.); in 0.5 part of boiling water, and 
in 1.5 part of glycerin. It has little value in medicine. 



100 DRUGS 



Ammonium Valerate. 



Ammonium Valerate (Ammonii Valeras, U. S.), should contain 
not less than 98 per cent, of pure Ammonium Valerate, and should 
be kept in well-stoppered bottles. It occurs in colorless, or white, 
quadrangular plates, emitting the odor of valeric acid, of a sharp 
and sweetish taste, and deliquescent in moist air. It is very soluble 
in water and in alcohol; also soluble in ether. 

This is the salt of ammonium commonly used in the nervous 
unrest of pregnant or hysterical women, or at the menopause in the 
peculiar nervous disorders apt to occur at that period. In poisonous 
doses it paralyzes the spinal cord in the lower animals. It is usually 
given in the form of the elixir of valerate of ammonium, the dose of 
which is a teaspoonful to a dessertspoonful, or it is combined with the 
bromides, under which circumstances it is much more efficacious. 
The dose of the salt itself is 10 to 15 grains (0.6-1.0). 

The sulphate of ammonium is never used in medicine. The 
phosphate of ammonium is employed in rheumatism, in the dose of 
10 to 20 grains (0.6-1.3). It is no longer official. 

The B. P. preparations besides those already given are: Phosphate 
of Ammonium, dose 5 to 20 grains (0.3-1.2), and Liquor Ammonii 
Citratis, dose 2 to 6 fluidrams (8.0-24.0). 

AMYL NITRITE. 

Amyl Nitrite (Amylis Nitris, U. S., Amyl Nitris, B. P.) is a liquid 
containing about 80 per cent, of Amyl (chiefly Iso-amyl) Nitrite 
(C5H11NO2). It should be kept in hermetically sealed glass bulbs, 
or in dark amber-colored, glass-stoppered vials, in a cool and dark 
place. It is a clear, yellowish liquid of a peculiar, ethereal, fruity 
odor, and pungent, aromatic taste. It is almost insoluble in water; 
miscible, in all proportions, with alcohol or ether. 

Amyl nitrite is very volatile, even at a low temperature, and is 
inflammable, burning with a yellow, luminous and sooty flame. It 
boils at about 96° to 99° C. (204.8° to 210.2° P.). It is made by 
the action of diluted sulphuric acid upon amylic alcohol and sodium 
nitrite. It is not to be confounded with nitrate of amyl, which has 
a different physiological action and is never used medicinally. 

Physiological Action.— When swallowed or inhaled, the drug pro- 
duces staggering, fulness in the head, roaring in the ears, duskiness 
of the face, and finally complete muscular relaxation, so that the 
animal or man falls to the ground. The heart beats very rapidly 
and forcibly, and the respiration becomes gasping. 

Nervous System.— Nitrite of amyl is the most rapidly acting of 
all the nervous depressants and sedatives which are used as medi- 
cines, except prussic acid. Experiments show that its dominant 



AMYL XI TRITE 



101 



>< 



action is on the motor side of the spinal cord. The motor cortex of 
the brain and the motor nerves are only affected by large amounts. 
Upon the nervous apparatus of sensation nitrite of amyl has no 
effect in medicinal amounts, and should never be used to relieve 
pain unless it be due to spasm or to angina pectoris. The muscles 
are depressed by toxic amounts. 

Circulation - .— When nitrite of amyl is used, the pulse becomes 
exceedingly rapid while the arterial tension speedily falls. The 
increase in pulse-rate is due to depression of the centric inhibitory 
apparatus (vagus centers) of the heart and to the sudden relaxation 
of the bloodvessels, by reason of which, the resistance being taken 
away, the heart beats faster. The fall of arterial pressure is chiefly 
due to depression of the muscular coats of the 
bloodvessels and also to slight depression of the 
vasomotor centers, but the bloodvessels of the 
pulmonary system are constricted by the nitrites. 
In very small amounts the drug stimulates the 
heart-muscle (Reichert), but its dominant action 
on the heart is that of a depressant. 

The Blood.— In large medicinal dose this drug- 
produces a chocolate color of the arterial blood, 
to the change of oxyhemoglobin into methemo- 
globin. 

Urine and Elimination.— The urine sometimes 
contains sugar after the use of nitrite of amyl, and 
there is increased diuresis. The drug is eliminated 
very rapidly from the body by the lungs and 
kidneys. 

Temperature.— If the nitrite of amyl be em- 
ployed for any length of time, a most remarkable 
fall in bodily temperature ensues, which is prob- 
ably due to diminished oxidation, but possibly to 
some effect on the heat-centers governing heat- 
production and dissipation. The vascular dila- 
tation also tends to aid greatly in the loss of bodily heat produced 
by the drug. 

Therapeutics.— Nitrite of amyl is used to relax general or local 
muscular spasms, for the relaxation of the spasm of epilepsy and for 
aborting an on-coming fit, for the prevention and subjugation of 
strychnine convulsions and tetanus, and for the relief of angina pec- 
toris, provided the attack is accompanied by high arterial tension. 
It may be used in puerperal eclampsia, but it is a dangerous remedy 
because of its relaxation of the uterus and the consequent danger of 
postpartum hemorrhage. Nitrite of amyl by inhalation is the best 
remedy to check hemoptysis, because it constricts the pulmonary vessels 
and simultaneously relaxes the systemic circulation, thereby diminishing 
the flow of blood to the lungs. In dysmenorrhea with uterine spasm it 



Fig. 8. — Nitrite of 
amyl depresses the 
motor or crossed 
pyramidal tracts of 
the spinal cord. 



102 DRUGS 

often gives great relief but nitroglycerin is better. Nitrite of amyl has 
been used in cases of seasickness as a prophylactic and cure with consid- 
erable success, but its action is so severe and so fleeting, and its depres- 
sant effect on blood-pressure so strong that I would never employ it. 
In cardiac failure from fright or anesthetics amyl nitrite is of some 
value when given in single whiffs. If it does not act favorably in 
restoring cardiac action at once, it is worse than useless to push it. 
It has also been found of value in whooping-cough, laryngismus 
stridulus, asthma, spasmodic croup, and infantile convulsions. In 
migraine, with local vasomotor spasm and true hemicrania, it is very 
useful. In strychnine poisoning and tetanus it must be inhaled 
between the spasms or else given hypodermically, as the respiratory 
cramp prevents its inhalation. 

Administration.— The drug may be given by placing three to five 
drops on a handkerchief and inhaling the fumes, or it may be dropped 
on sugar and taken by the mouth in the same quantity. The best 
way for patients to use the drug is to have it in hollow pearls of 
glass, each holding 5 or 10 minims (0.3-0.06). One or more of these 
may be crushed in a handkerchief and the fumes inhaled. 

It is important to remember the fact that the effects of the drug 
are more severe for a moment after its use than during its inhalation. 
The physician should warn the patient that the effect of the drug is 
sudden and alarming, and in nervous cases should direct that the 
inhalations be made slowly, as a very full inhalation may produce 
unpleasant sensations of cardiac oppression. 

ANTHRAROBIN. 

Anthrarobin seems to possess equal value with its relative chrysa- 
robin, and to be capable of acting as efficaciously as this substance 
in the treatment of skin diseases. It is a yellowish powder, toler- 
ably stable in a dry atmosphere, not soluble in acids or water, but 
readily soluble in dilute alkaline solution or alcohol, at first making 
a solution of a brown color, which, as oxygen is taken up, changes 
to a green and finally to a violet hue. 

Therapeutically, anthrarobin has been employed by Rosenthal and 
by Behrend, and more recently Kobner has recorded his experience 
with it, employing it with good results in a 10 to 20 per cent, solu- 
tion in the various forms of tonsurans as a wash. Rosenthal has 
used it in psoriasis and pityriasis versicolor and herpes, and Behrend 
asserts that it is often better in its effects upon the skin than chrysa- 
robin, as it produces less inflammation and discolors the skin only 
slightly. It also possesses the additional value of making so slight 
a stain on the linen that it can be removed by washing. 

According to most authorities, it is best to keep the drug in alco- 
holic solution, and, if the bottle is well corked, such a mixture remains 
stable for a week. 



ANTIMONY 



103 



ANTIMONY. 



Antimony itself is rarely used in medicine, owing to its insolu- 
bility, but is generally employed as the tartrate of antimony and 
potassium, or Tartar Emetic (Antimonii et Potassii Tartras, U. S.; 
Antimonium Tartratum, B. P.), 
or in the form of the sulphide 
(Antimonii Sulphidum); purified 
sulphide (Antimonii Sulphidum 
Purificatum; Antimonium Nig- 
rum Purificatum, B. P.); and 
sulphurated antimony (Anti- 
monium Sulphuratum, B. P.), 
sometimes called Kermes Min- 
eral. The last three drugs are 
very rarely employed and are 
unreliable preparations, al- 
though some practitioners use 
kermes mineral as an alterative 
circulatory depressant and seda- 
tive expectorant in the dose of \ 
grain (0.01) every hour or two. 
As an emetic the dose of Kermes 
Mineral is 1 to 4 grains (0.06- 
0.25). 

The oxide of antimony (Anti- 
monii Oxidum, B. P.) forms 
part of the Pulvis Antimonialis. 

Tartar Emetic. 

Tartar Emetic (Antimonii et 
Potassii Tartras, U. S.; Anti- 
monium Tartaratum, B. P.) is 
made by boiling the oxide of 
antimony with bitartrate of 
potassium and water. Although 
it is really crystalline, it is gene- 
rally sold as a fine powder 
owing to the crystals being 

easily pulverized. It should contain not less than 98.5 per cent, 
of pure Antimony and Potassium Tartrate and occurs as colorless, 
transparent crystals of the rhombic system, becoming opaque and 
white on exposure to air, or as a white, granular powder; without 
odor, and having a sweet, afterward disagreeable metallic taste. 
It is soluble in 12 parts of water at 25° C. (77° F.), and in 3 parts of 




Fig. 9. — A, antimony depresses the 
heart muscle; B, antimony depresses the 
peripheral portions of the vasomotor sys- 
tem in the bloodvessels; C, antimony de- 
presses the vasomotor center; D, the res- 
piratory center. 



104 , DRUGS 

boiling water, but insoluble in alcohol, which precipitates it from 
its aqueous solution in the form of a crystalline powder. 

Owing to its chemical constitution tartar emetic should never 
be given with either acids or alkalies, and all drugs containing tannic 
acid are also incompatible with it, owing to the fact that an insoluble 
tannate is rapidly formed, which is absorbed very slowly if at all. 
So complete is the insolubility of the compound so formed that tannic 
acid is the best chemical antidote to the drug that we possess. 

Physiological Action.— Tartar emetic, when applied to mucous 
membranes, produces a burning sensation, and upon the skin it may 
readily cause intense irritation if the part be delicate. If kept in 
contact with a mucous membrane, very distinct inflammatory changes 
occur, and if it be applied to the skin for any length of time, redness, 
followed by acne of a pustular character, appears, which finally 
ends in ulceration and sloughing if the use of the drug is persisted in. 
Under these circumstances the vitality of the parts seems interfered 
with, and, as a result, healing takes place very slowly indeed. 

Nervous System.— Antimony is a depressant to the sensory side 
of the spinal cord, and a paralyzant to all the spinal centers, motor 
and sensory, in poisonous dose. 

It is stated that when an animal is under its influence sensation to 
heat and acids is lost before the ordinary sense of touch is destroyed. 
The convulsions which sometimes ensue after poisonous doses in 
the lower animals are due to anemia of the brain brought on by the 
circulatory depression. Ringer and Murrell have proved antimony 
to be a motor-nerve and muscle poison. 

Circulation.— The chief influence of antimony is exerted upon 
the circulation. In small doses it lowers the pulse-rate by a direct 
depression of the heart-muscle, and simultaneously decreases arterial 
tension by an action upon the peripheral portions of the vasomotor 
system in the walls of the bloodvessels, but the vasomotor influences 
may be in part centric, and this question must be considered as sub 
judice. The fall of arterial pressure is also due to failure of heart- 
force. With the lowering of the pulse-rate there is nearly always 
a corresponding decrease in cardiac power. 

When poisonous doses are employed, death ensues after great 
circulatory and respiratory depression, as will be seen below. The 
heart is found after death relaxed and flabby and wholly unrespon- 
sive to all stimuli, although in one of the lower animals, such as the 
frog, if the dose has not been very excessive and digitalis is freely 
employed, the heart may be made to beat again. In man, it is 
hardly necessary to state, the digitalis must be used early to render 
much service. The drug in poisonous doses is thought to depress 
the peripheral ends of the vagus nerves. 

Respiration.— The drug has little or no effect upon respiration 
except when given in lethal doses. Under these circumstances death 
is produced in three ways, all of them acting together. Primarily, 



ANTIMONY 



105 



the respirator}' center in the medulla is depressed, and the governing 
nerves of breathing, the pneumogastrics, are also rendered inactive; 
secondarily, the cardiac failure speedily causes pulmonary congestion; 
and thirdly, the drug causes such an outpouring of liquid mucus into 
the bronchial tubes that the patient is drowned in his own secretions 
which he is too weak to expel. 

Stomach axd Intestines.— Antimony in toxic doses is a powerful 
irritant to these portions of the body. In full medicinal amounts it 
acts as a slow but powerful emetic, producing much nausea, The 
vomiting is due to an action on the vomiting center in the medulla 
and to a direct action on the stomach itself. The drug is, therefore, 
a centric and peripheral emetic. Very full doses produce watery 
purging, attended with some griping and tenesmus. 

Elimination. — Antimony es- 
capes from the body in all the 
secretions, but largely by the 
bowels. The latter method of 
elimination seems chiefly to follow 
poisonous doses, and purging is 
an effort at elimination. 

Therapeutics.— Tartar emetic is 
employed for at least five separate 
purposes, the most usual of which 
is as a circulatory quieter and seda- 
tive. The indications for antimony 
as a circulator}' depressant are 
not so generally recognized at 
present as they were at one time, 
on account of the introduction of 
other drugs. All states of sthenic 
inflammation with a bounding pulse, 
high fever, and symptoms show- 
ing the patient to be possessed of robust constitution permit of its 
use, while all asthenic conditions most emphatically contraindicate 
its employment. In the treatment of colds, to break "forming diseases, 
and to allay inflammation it is given in moderate dose. It is useful 
in sthenic bronchitis as an expectorant. Under these circumstances it 
may be given in emetic dose; or, if emesis is not desirable, minute 
amounts given hourly are of value, such as fa grain (0.001) every 
hour, or a teaspoonful of a solution of \ grain (0.03) to 4 ounces 
(120 cc) of water every hour may be used. This is a particularly 
useful method in children, as the solution is tasteless and it does not 
produce nausea and vomiting. 

Most modern practitioners have ceased to use this drug because the 
depressant plan of treatment is out of favor, and because the effects 
of the vegetable cardiac sedatives are more easily controlled. 

As an emetic antimony is slow but forcible, it ought not to be 




Fig. 10. — A, antimony stimulates 
the vomiting center; B, antimony 
irritates the gastric mucous membrane. 



106 DRUGS 

used in cases of poisoning by other drugs, owing to its depressant 
effects and slowness of action. 

Before the introduction of anesthetics emetic doses were employed 
to relax the muscles in reducing dislocations and fractures. 

Tartar emetic is harmful if irritation of the stomach is present 
or if renal inflammation is present. If one good-sized emetic dose 
is not sufficient to produce vomiting, it should not be repeated, but 
some other emetic or the stomach-pump be used, lest antimonial 
poisoning complicate the case. The emetic dose must be large 
enough to be effective, or none at all should be given. If this rule 
is disregarded, systemic changes come on with undesirable severity 
in those cases where emesis fails to occur because of small doses. 

As a counterirritant antimony is employed in the form of an oint- 
ment whenever a very slowly acting and prolonged counterirritation 
is to be maintained in old enlargements of the joints. 

Antimony is an efficient diaphoretic, but its use is undesirable, 
owing to its disagreeable effects, such as nausea and intestinal dis- 
turbance, and because other, more pleasant, drugs act equally well. 

Administration.— The dose of tartar emetic when there is an 
excited circulation is ^V to yq grain (0.003-0.006) every three hours 
until an effect is obtained. As an emetic the dose is \ to 1 grain 
(0.03-0.06). The compound pill of antimony (Pilulce Antimonii 
Composite, or Plummer's pill), was used as an alterative, and contains 
sulphurated antimony J grain (0.03), calomel f grain (0.03), guaiac 
1 grain (0.06) ; the dose is one to three pills. 

The ointment of antimony (Unguentum Antimonii Tartar uti) is 
used externally as a counterirritant spread on a rag or piece of lint. 
Antimonial powder (Pulvis Antimonialis, B. P.), or James's powder, 
contains oxide of antimony and phosphate of calcium, and is given 
occasionally as an antipyretic in the treatment of rheumatism and 
fever in the dose of 3 to 6 grains (0.2-0.4) ; it is best given in a pill. 

The compound syrup of squill (Syrupus Scillce Compositus, U. S.), 
otherwise known as "Coxe's Hive Syrup," contains J grain (0.045) 
of tartar emetic to the ounce. The dose is 20 to 30 minims (1.3-2.0) 
for an adult as a sedative, or from this amount to 1 dram (4.0) to 
a child as an emetic. 

Poisoning.— When toxic doses of tartar emetic are taken, the 
pulse at first becomes slightly weaker and slower, the skin becomes 
moist and relaxed, a general sense of relaxation comes on, and 
simultaneously a sensation of severe nausea and gastric distress 
appears. 

Following this condition violent vomiting asserts itself. The 
ejected mass consists of the contents of the stomach— mucus, bile, 
and watery fluids, perhaps blood. Purging appears almost as early 
as the vomiting, and consists first of the normal contents of the 
intestines, then mucus, then bile, and, very rarely, blood. These 



ANTIMONY 107 

signs may rapidly pass away and the characteristic "rice-water 
stools" 1 of antiinonial poisoning appear. The general condition of 
the patient is now most serious. The face is pinched, livid, and 
covered with a cold sweat. The pulse is rapid and shuttle-like— to 
and fro— or lost at the wrist; the arterial tension is almost nil. The 
respirations are faint and fluttering, and so shallow as hardly to be 
seen or heard. Cramps in the calves of the legs attack the patient, 
due to the abstraction of water from the tissues by the violent purg- 
ing, and the temperature falls lower and lower as death approaches. 
The general condition is such that all the signs point to Asiatic 
cholera, and antimonial poisoning cannot be distinguished from this 
disease during an epidemic without a history of the case or a chemical 
analysis of the secretions, which ought always to be preserved. 2 

The treatment of antimonial poisoning consists in the internal 
administration of large amounts of tannic acid to form the insoluble 
tannate of antimony, in the use of the stomach-pump, and in the 
maintenance of an absolutely dorsal position. When tannic acid 
cannot be had, ordinary tea leaves may be boiled and the decoction 
given as an antidote and stimulant. The patient should vomit into 
towels and not raise the head from the pillow; the head, indeed, 
should generally be placed lower than the heels. External heat, 
atropine and digitalis should be used freely, and morphine should be 
employed hypodermically to allay pain and irritation unless the 
respirations are too feeble. If the opium is greatly needed because 
of pain, and yet seems contraindicated because of depression, it 
should be accompanied by strychnine to stimulate the respiratory 
center and overcome any depression produced by the opium. 

Fatty degeneration of all organs may occur as a result of acute 
antimonial poisoning. 

Chronic poisoning by antimony is quite a rare affection, but it occurs 
chiefly in type-founders and type-setters. McTValter has reported 
instances in which peripheral neuritis, disorders of the bladder, and 
irritability of the prostate developed in these artisans. Headache, 
abdominal tenderness, and an irritable state of the mucous membranes 
were also present, associated with profound mental depression and 
circulatory feebleness. These facts are of interest because it is a 
superstition among some of the lower classes that the administration 
of antimony will cure the alcoholic habit, and if given for a long 
time these symptoms and fatty degeneration might ensue, leading 
to suspicion of attempted murder by poison. 

1 A "rice-water stool" is one which, on standing in a glass, separates into two layers, 
the lower white and flocculent, the upper water and almost clear. 

2 This is a good opportunity to state that the secretions and excretions of a person 
dying of any poison should be placed in a chemically-clean jar capable of being sealed. 
The same rule of cleanliness applies to the jars holding organs at the postmortem. 
The jars should be at hand, and no intermediate vessel used. They should be sealed 
at once, and kept so until claimed by the authorities. 



10S DRUGS 



ANTIPYRINE. 



Antipyrine (Antipyrina, U. S.; Phenazonum, B. P.) is a derivative 
of coal-tar, its chemical name being phenyldimethylpyrazolon. It 
was discovered by Ludwig Knorr in 1884, and introduced into medi- 
cine by Filehne. Antipyrine is a white powder of a somewhat bitter 
taste, and is very soluble in water, less so in ether, alcohol, and 
chloroform. 

When antipyrine is given to a man in full medicinal amount, it 
causes a sensation of buzzing and tightness of the head not unlike 
that produced by quinine. The bodily temperature, if normal, is 
depressed a fraction of a degree, but no other symptoms are mani- 
fested. If the dose be quite large, some blueness of the lips and 
finger nails appears, chilly sensations are experienced, and finally a 
profuse sweat breaks out over the entire body, which is more severe 
if fever has previously existed. Large doses sometimes cause nausea 
and vomiting. 

Physiological Action.— Nervous System.— When a large poison- 
ous dose of antipyrine is given to one of the lower animals, relaxa- 
tion, complete loss of reflex action, and total inability to move come 
on at once, and death ensues. Somewhat smaller doses produce 
exceedingly severe tetanic and epileptiform convulsions, but con- 
sciousness seems to be preserved. It has been proved that the chief 
cause of the convulsion is an action of the drug on the brain. 1 Very 
large toxic doses, therefore, decrease reflex action, and smaller ones 
increase it, though medicinal amounts certainly lessen reflex activity 
to a notable degree. The cause of this failure of reflexes is depres- 
sion of the sensory nerves and the receptive centers of the spinal 
cord. Medicinal amounts must, therefore, be regarded as very dis- 
tinct nervous sedatives, acting much more actively on the nerves 
of sensation than on those of motion. Injected beneath the skin or 
applied to a mucous membrane, antipyrine is a powerful local anes- 
thetic, the anesthesia lasting often for several days. 

Circulation.— The studies of a very large number of pharma- 
cologists prove most conclusively that antipyrine in moderate doses 
has no effect on the circulation of the lower animals unless these be 
so frequently repeated that cumulative effects ensue. Many reliable 
clinical observers have asserted that the drug depresses the circula- 
tion in man in some cases, and antipyrine is certainly not a cardiac 
stimulant. The writer is confident, however, that antipyrine is not 
so distinctly a cardiac depressant as some believe. On the other 
hand, there can be no doubt that in some persons it tends to lower 
arterial tension and so to produce syncope. It must therefore be 
used with caution in cases which have a feeble circulation. Large, 

1 See author's Boylston Prize Essay of Harvard University, on Antipyretics. 



ANTIPYRINE 109 

poisonous doses lower blood-pressure unless convulsions are present, 
when the pressure is raised. In many of the cases where vascular 
depression and collapse have followed its use it has been employed 
in excessive amounts or the fall in bodily temperature has caused 
the untoward symptoms. (See Fever and its Treatment.) 

Blood.— No spectroscopic changes in the blood follow the use of 
medicinal doses of antipyrine in the ordinary individual, but in poi- 
sonous amounts it produces methemoglobin. If the doses be toxic 
or idiosyncrasy exists, cyanosis may come on. That the blood is not 
destroyed by small amounts is proved by the absence of hematin in 
the urine of persons taking the drug. The corpuscles suffer no 
changes except in very pronounced poisoning, when they are said to 
become crenated and shrivelled. 

Respiration.— When antipyrine is given in lethal doses, death 
results from failure of the respiratory center. Ordinary doses have no 
effect on this function, but large ones make the breathing more rapid. 

Temperature.— In normal men and animals antipyrine in medi- 
cinal dose may be considered as without effect so far as bodily 
temperature is concerned. In fevered animals it has been found to 
lower temperature by decreasing heat-production and increasing heat- 
dissipation. That it does not do this by an action on the blood 
seems proved by the fact that the blood is not affected by medicinal 
amounts. The sweating does not cause the fall since it takes place 
when no sweating occurs. It may, therefore, be considered that the 
drug directly affects the nervous heat-mechanism of the body. 

Kidneys, Tissue-waste, and Urine.— A large number of studies 
made upon man and the lower animals by competent investigators 
have brought about very considerable advances in our knowledge of 
the influence of antipyrine upon tissue- waste. It is useless to burden 
this volume with a discussion of their methods and results, which 
may be found in the author's Essay on Antipyretics. Suffice it to say 
that, while all observers are not agreed as to the effects produced, the 
deductions apparently to be drawn are that the drug diminishes the 
quantity of the urine excreted, and also decreases the elimination of 
the results of nitrogenous tissue-metamorphosis— or, in other words, 
is a conservator of the tissues of the body. 

Elimination.— The elimination of antipyrine goes on very rapidly 
indeed, and begins almost at once after its ingestion. Maragliano 
and Reihlen state that it appears in the urine in three hours after it 
is taken, so that at the fourth hour elimination is at its height, 
although it continues to be eliminated for twenty-four or perhaps 
thirty-six hours. According to Pavlinow, part of the antipyrine 
ingested is eliminated by the salivary glands. 

Poisoning.— The treatment of poisoning by antipyrine consists in 
the administration of stimulants, the maintenance of bodily heat, the 
use of atropine to restore the tone of the vascular system, and, if 
cyanosis is alarming, the employment of oxygen inhalations. 



110 DRUGS 

Antiseptic Power.— Antipyrine exerts a very distinct antiseptic 
action in small amounts, delays all forms of fermentation, and 
destroys germs when it is present in large quantity. 

Therapeutics.— Antipyrine is employed in medicine for two great 
purposes— namely, for the reduction of fever and the relief of pain — 
but its employment as an antipyretic is now far surpassed by its use 
as an analgesic. 

As an antipyretic, antipyrine should be given in a few full doses 
rather than frequent small ones, as a general rule, since if the fever 
is of any severity the latter method of administering it will have no 
antipyretic effect, and the constant dosing will produce a gradual 
saturation of the system without causing a fall of temperature. On 
the other hand, too large doses may depress the temperature to a 
point below normal and induce collapse. In the article on Fevers 
(Part IV) the conditions are indicated in which the drug is best 
employed, these being the sthenic fevers as a rule, or instances where 
excessive outbursts of fever necessitate prompt reduction of tem- 
perature. In excessively high temperature in pneumonia it has been 
used, and in scarlet fever and smallpox antipyrine is occasionally of 
service, although in pneumonia, as a rule, the condition of the patient 
indicates the use of cold to the chest as a local measure for the reduc- 
tion of congestion or the use of cold sponging to relieve fever. (See 
Pneumonia.} The use of the cold applications is always to be preferred 
to antipyrine in the reduction of fever, since they are safer, more reliable, 
and do not strain the kidneys, reduce the blood, or depress the heart in 
feeble patients. (See Cold and Fever.) When cold water cannot 
be used, then antipyrine may be employed. In phthisis antipyrine 
generally increases the sweating, produces oppression, and either fails 
to act as an antipyretic or causes collapse by exercising too great an 
effect. In sunstroke it frequently fails to influence the temperature, 
and ought not to be used. 

Be the fever what it may, provided it be associated with any dis- 
ease process, antipyrine is useless so far as any influence over the 
course of the disease itself is concerned. It is a remedy used in the 
treatment of the symptoms, not for the removal of the cause of the 
fever. 

As an analgesic antipyrine is in some cases the peer of opium. 
Although the latter drug will relieve all forms of pain if it be pushed, 
it possesses many disadvantages not found in antipyrine. In deep- 
seated pains due to disease of the organs of the body, in inflammations 
and similar disturbances, antipyrine is useless. In neuralgic affec- 
tions of all kinds it finds its sphere, particularly if the disorder be 
rheumatic, gouty, or due to nervous depression from nervous exhaus- 
tion or disease. Under the latter circumstances it is best combined 
with caffeine and a little bromide of potassium. In other cases a 
capsule containing 5 grains (0.3) of antipyrine and 5 grains (0.3) of 
chloral may be given to relieve pain and cause sleep. This com- 



ANTIPYRINE 111 

bination undergoes deliquescence without impairing its usefulness. 
(See Neuralgia.) In acute rheumatism it will give relief in a fairly 
large number of cases, not only relieving the pain and fever if they 
be present, but also actually modifying the disease. It seems, how- 
ever, to increase sweating in acute articular rheumatism. In gold 
it is stated to have a specific curative effect upon the disease over 
and above the relief of the pain, but this is questionable. A useful 
remedy in gouty neuralgia and muscular rheumatism is such a pre- 
scription as follows: 

3 — Antipyrinse gr. xxiv (1.6) 

Strontii salicylates . gr. xlviij (3.0) 

Elixiris aromatici f5iij (90.0).— M. 

S. — Tablespoonful every hour for three doses in severe neuralgia, or three times a 
day for muscular rheumatism. 

Its use in dysmenorrhea has been recommended, but its beneficial 
influence except in neuralgic cases is doubtful. At one time it was 
thought that its use would relieve the pains of labor, but this has, 
unfortunately, proved untrue. It may, however, be tried, when 
suffering is very severe, in the dose of 15 grains (1.0). In the severe 
lancinating or darting pains of locomotor ataxia, and in the laryngeal 
and gastric crises complicating this disease, antipyrine is a valuable 
remedy. Curiously enough, it seems to subdue acute attacks of pain 
in posterior sclerosis, but it fails to control the slighter pains and 
muscular twitchings sometimes seen in this disease and in myelitis. 

Some clinicians have used antipyrine with asserted great success in 
diabetes mellitus. In such instances the disease often depends on a 
gouty diathesis, and can be as well relieved by salicylates. 

Antipyrine may be used hypodermically (2 grains (0.15) to 20 minims 
(1.3) of water) in the region of a hypersensitive nerve as a local anes- 
thetic. The anesthesia produced by it lasts for several days, but the 
pain immediately after the injection is severe. 

Antipyrine is sometimes a very useful remedy in modifying the 
severity of epilepsy. (See Epilepsy.) 

In whooping-cough antipyrine has more frequently given relief in 
the writer's experience than any other remedy. It should be given 
to a child of five years in the dose of 2 grains (0.12) every four or 
five hours, the patient being watched for cyanosis and the drug 
stopped as soon as this symptom appears. Antipyrine generally 
decreases the frequency rather than the severity of the attacks of 
cough. 

In malarial diseases antipyrine certainly exercises no antiperiodic 
influence, although it controls the febrile paroxysms to a great extent. 
One cannot help thinking that frequently where antipyrine has been 
reported as acting as an antiperiodic it has simply lowered the fever, 
and so seemed to influence the disease. 

In acute coryza the temporary relief produced by applying cocaine 
to the engorged Schneiderian membrane may be prolonged very 



112 DRUGS 

greatly by the use of a solution of antipyrine in the strength of 4 per 
cent. This produces a smarting sensation, which speedily passes 
away. The same treatment is of value in inflammations of the 
larynx and pharynx. Should cocaine solutions not precede the 
antipyrine, the primary irritant effects persist unless the strength 
of the solution of antipyrine is reduced to 1 or 2 per cent. It is 
always better to precede its use by cocaine. 

Locally applied, antipyrine possesses very distinct hemostatic prop- 
er,ties, and for this purpose may be used in a 4 per cent, solution, either 
in liquid or in a spray. Under these circumstances it seems to act 
not by producing clots, which are disadvantageous from the stand- 
point of antisepsis, but by constringing the bleeding vessels. This 
hemostatic property is very materially increased if a solution of tan- 
nic acid is added to it, when it forms a glutinous precipitate which 
controls the hemorrhage. The precipitate is best applied by means 
of a swab. 

Antipyrine may be given with cocaine in suppository to check 
bleeding from hemorrhoids and relieve rectal pain. The cocaine 
must be used to prevent the antipyrine from causing pain when the 
suppository is first introduced. 

Untoward Effects.— Aside from the results of poisonous doses, a 
certain number of cases taking this drug present slight cyanosis or 
duskiness of the hands and of the face about the nose and lips; the 
fingers may be cold and clammy, and the feet are often very cold; 
sweating is a very common symptom of the untoward influence of 
antipyrine, and pricking or tingling of the skin is not uncommonly 
seen. By far the largest number of these cases, however, suffer 
from disorders associated with the skin, and erythematous patches 
may be seen everywhere, more particularly on the hands and feet 
and about the face, arms, and chest. Occasionally pemphigus-like 
spots appear, and often large bullae have been noted as present. 
Elsewhere are published the statistics, collected from medical litera- 
ture, of 121 cases of untoward effects exercised by antipyrine. 1 An 
analysis of these shows that females were much more frequently 
affected than males, and that the most susceptible age was decidedly 
that of full adult life— namely, from thirty to forty years in both 
sexes. The dose causing these effects was most commonly a mod- 
erate one— from 10 to 15 grains (0.6-1.0), or even from 4 to 10 
grains (0.25-0.6). This fact hold good with regard to both sexes. 
The time of onset of the symptoms varied somewhat according to 
whether the drug was given in one excessive dose or in frequently 
repeated medicinal doses. In many instances the appearance of the 
symptoms was sudden rather than gradual. As a rule, the duration 
of the symptoms did not exceed one to three hours, three days being 
the longest time mentioned. It is interesting to note, however, that 

1 See author's Boylston Prize Essay of Harvard University, on Antipyretics. 



APIOL 113 

of all these cases only 6 proved fatal, and in these there was ample 
cause for death aside from any effect of the drug. We can rest 
assured, therefore, in ordinary cases of disease that patients exhibit- 
ing untoward effects of antipyrine are not in any acute danger, 
although the symptoms may be temporarily most alarming. Typhoid 
fever seems according to the statistics collected by the writer, to 
be the disease in which this unexpected influence manifests itself 
most frequently, but this may be due to the fact that it is so common 
a malady and is so frequently treated by means of antipyretics. 
Brunton is responsible for the statement that antipyrine is particu- 
larly prone to produce collapse in menstruating women. Falck 
has collected a large number of cases of antipyrinism, and quotes 
Pusinelli as having seen vomiting often follow the use of this drug. 

Antipyrine very distinctly increases susceptibility of patients to 
taking cold, and ought not to be used by those who are forced to go 
out of doors in cold weather. 

Administration.— Owing to the solubility of antipyrine, it is most 
readily given in a little water in a wineglass or spoon. If its slight 
taste is disliked, it may be dissolved in any one of the aromatic 
waters or in elixir of bitter orange peel or some similar vehicle. 
Most persons prefer to take it in tablet form. The amount which 
may be given at a dose is 5 to 20 grains (0.3-1.3), but 3 to 5 grains 
(0.2-0.3) is the best dose in most cases, at least until it is determined 
how well it is borne. 

Incompatibles.— When added to sweet spirit of nitre, antipyrine in 
the course of a few moments produces a blue, changing to a dark- 
green color, owing to the formation of iso-nitroso-antipyrine which 
is not poisonous, but which in the form of a dry powder is readily 
oxidized on exposure to slight heat. If this color is not formed, the 
spirit of nitre lacks its nitrous ether, and is worthless, so that we 
have not only another incompatibility to remember, but a new means 
of testing the therapeutic value of all samples of sweet spirit of nitre 
which may be dispensed. Antipyrine is also incompatible with the 
salts of iron, calomel, corrosive sublimate, and phenol. With salicy- 
late of sodium it forms a pasty mass; with chloral an oily liquid. 
Betanaphtol and tannic acid are also incompatible with it. Tannic 
acid and non-alcoholic solutions of tannic acid form an insoluble 
precipitate with antipyrine as does also the tincture of iodine. 



ANTITOXIN. 
(See Part III.) 

APIOL. 

Apiol is a camphoraceous body, derived from common parsley or 
P etroselinum , U. S. As its melting-point is very low, it cannot be 

8 



114 DRUGS 

kept in solid form, and is always dispensed in 75 per cent, solution. 
So far as is known to the author, no careful study of its physiologi- 
cal action has ever been made, but two French observers, Joret and 
Homolle, state that in overdose it causes ringing in the ears, intoxi- 
cation, and severe frontal headache. The official preparation is 
Oleoresina Petroselini, U. S., dose, 5 grains (0.3). 

Therapeutics.— Originally introduced to combat malarial fevers, 
because of a fancied resemblance in its toxic action to quinine, apiol 
has found its level as a remedy in amenorrhea, given in the dose of 
2 to 8 minims (0.1-0.5) three times a day for a. week before the 
expected date of menstruation. It should be given, if possible, 
in capsules, owing to its unpleasant taste. It is said not to possess 
any abortifacient influence, although it is often taken with this object 
in view. 

Apiol is imported from France in capsules containing a little less 
than 3 minims (0.2), and is also put up in soft elastic capsules in 
the United States. 

APOCYNUM. 

Apocynum Cannabinum should not be confused with Apocynum 
Androsimcefolium, which has few of its properties, but which is 
often employed by mistake for the real drug. When good effects do 
not follow the use of the drug another sample should be tried. The 
remedy in overdose is capable of causing vomiting and purging 
through gastro-intestinal irritation, but in medicinal dose rarely does 
so. It is employed in medicine for the relief of cardiac and renal 
dropsy of the subacute or chronic type, and is best given in the form 
of the tincture or fluidextract in the dose of 5 to 20 minims (0.3-1.3) 
of the former or 1 to 5 minims (0.05-0.3) of the latter. Under its 
influence profuse diuresis occurs, and the fluid is said to be removed 
so rapidly that the drug has been called the "vegetable trocar." 

Physiological studies show that the action of the drug on the heart 
is similar to that of digitalis, as it slows the pulse and raises blood- 
pressure. I have not obtained satisfactory effects from its use. 

APOMORPHINE. 

Apomorphin(B hydrochloridum, U. S. (HCI.C17H17NO2) of an arti- 
ficial alkaloid, prepared from morphine by the abstraction of one mole- 
cule of water. It should be kept in small, well-stoppered vials, which 
have been previously rinsed with diluted hydrochloric acid and dried. 
It occurs as minute grayish-white monoclinic prisms, glistening, 
odorless, having a slightly bitter taste, and acquiring a greenish 
tint upon exposure to light and air. 

It is soluble in 50 parts of water, 50 parts of alcohol, 1864 parts 
of ether, and in 3800 parts of chloroform at 25° C. (77° F.); soluble 
iml7 L parts of water at 80° C. (176° F.). It is obtained by the action 



APOMORPHINE 



115 



of hydrochloric acid upon morphine in a sealed tube to which is 
applied a high heat. A very important point to remember is that 
its solutions rapidly decompose, and, if then employed, may produce 
poisonous symptoms. The drug ought to be freshly dissolved each 
time it is used. If the salt imparts an emerald-green color to 100 
parts of water when shaken a few times, it should be rejected, unless 
it is found that the water contains small amounts of ammonia, 
which is supposed to be active in causing such a change. 

According to Boyer and Guinard, there are two kinds of apomor- 
phine sold. Each has a physiological effect different from that of the 
other. The crystalline form, which is the one always to be employed, 
causes, in overdose, irritation, spasms, trismus, vertigo, and hyper- 
esthesia; while the amorphous form (never to be used) causes col- 
lapse, hypothermia, general weakness, feebleness of the heart and 
respiration, and anesthesia. 

Physiological Action.— One 
of the best studies of this 
drug is that of Reichert, who 
found that in poisonous doses 
it produces convulsions, and 
finally paralysis, both of which 
are chiefly spinal in origin. 

Nervous System.— On the 
nervous centers in the brain 
apomorphine acts as a seda- 
tive in medicinal doses, but 
the convulsions produced by 
poisonous doses are probably 
spinal. The motor and sen- 
sory nerves are paralyzed by 
poisonous doses, and even the 
muscles become poisoned 
and incapable of contraction. 
Medicinal doses have no effect. 

Circulation.— When given in moderate amounts, apomorphine 
increases the rapidity and force of the pulse and raises arterial press- 
ure by stimulation of the accelerator nerves and the vasomotor 
centers. In large doses it acts as a circulatory depressant. 

Respiration.— After ordinary amounts no changes in respiration 
occur, but after poisonous doses the breathing becomes rapid and 
irregular. 

Vomiting.— Vomiting is produced by a direct action of the drug 
upon the vomiting centers in the medulla, and not by an action on 
the stomach. Apomorphine is, therefore, a typical centric emetic. 

Therapeutics.— Apomorphine is useful in nearly all cases where an 
emetic may be employed. In poisoning from other drugs, particu- 
larly depressants and narcotics, we have little knowledge of its safety, 




Fig. 11. — A, apomorphine stimulates vomiting 
center in the medulla. 



116 DRUGS 

but unless the stupor or circulatory change is very profound, the 
drug may be used with care. Often a hysterical patient can be 
brought to herself by an apomorphine vomit. In subacute and 
chronic catarrh of the stomach and air-passages it may aid in getting 
rid of the mucus by emesis, and in non-emetic dose it is a useful 
remedy in acute bronchitis when the secretion is very scanty. Non- 
emetic doses, given hypodermically, of ^ grain (0.002) have been 
used as often as every three hours with notable success in producing 
nervous quiet in uremia, alcoholic excitement and delirium tremens, and 
if combined with T \$ grain of hyoscine it is particularly efficacious 
in the latter states. 

Untoward Effects.— Apomorphine rarely causes disagreeable effects, 
but there are cases on record in which it has produced serious symp- 
toms even when given in ordinary doses. These symptoms have 
consisted in depression and collapse. One-fifteenth grain is said to 
have caused death in a woman who had bronchitis, but was other- 
wise healthy. Probably in these cases the amorphous form was used. 

Administration.— The drug when used as an emetic should always 
be given hypodermically and the solution be freshly prepared. The 
emetic dose is about to grain (0.006), but as much as i grain (0.012) 
may be used in strong patients. The expectorant dose is 4V to 2V 
grain (0.0015-0.003) by the mouth. No nausea is usually felt. 
The drug nearly always acts badly in children, and it is better not 
to use it in this class of patients. The salt used is Apomorphine 
Hydrochloridum, U. S. and B. P. An injection (Injectio Apomor- 
phince Hypodermica) — 1 grain (0.06) dissolved in 110 minims (7.1) 
of distilled water with 1 minim (0.06) of diluted hydrochloric acid— 
is official in the B. P. 

APOTHESINE. 

Apothesine is a local anesthetic which is chemically the cinnamic 
ester of gamma-diethylamino-prophyl-alcohol hydrochloride. It 
appears in snow-white crystals and is readily soluble in water, in 
alcohol, and slightly so in ether and acetone. It is said to be slightly 
less toxic to animals than procaine and is used for exactly the same 
purposes, with or without adrenalin, for local and infiltration anes- 
thesia and has proved generally efficient whenever a local anesthetic 
is indicated. It does not constrict the tissues as does cocaine. It 
is placed on the market in small hypodermic tablets. The strength 
employed is usually 1 to 2 per cent, in salt solution. It can be 
sterilized by boiling. It does not produce a habit and does not come 
under the narcotic law. 

ARGYROL. 

Argyrol is a proprietary salt of silver, which is far less irritating 
than nitrate of silver, but is not so efficient as a germicide or anti- 
septic. It is important to use freshly prepared solutions. Its lack 
of irritating properties has, however, rendered it popular in a large 



ARSENIC 117 

number of conditions in which the nitrate of silver has hitherto been 
used. In cystitis 1 ounce of a 10 to 25 per cent, solution may be 
injected into the bladder and permitted to remain there some minutes 
before being passed or drawn off. When employed in gonorrhea a 
16 per cent, solution may be injected four times in the twenty-four 
hours with advantage. To prevent or relieve ophthalmia neonatorum 
the strength of the solution should be 25 per cent. Stains caused by 
argyrol can be removed by the use of a 1 : 500 solution of corrosive 
sublimate. 

ARISTOL. 

(See Thymol Iodide.) 

ARNICA. 

Arnica (U. S.) is the dried flower heads of Arnica montana, a 
native plant of the Western United States and Europe. It holds 
a very high position in domestic medicine as a local and internal 
remedy in sprains and bruises, and in the treatment of passive 
hemorrhages, amenorrhea and similar states. 

Physiological Action.— When arnica is applied to a delicate skin, 
it produces burning and irritation, and even extensive skin lesions. 
According to the studies of the author, it slows the pulse, raises 
the blood-pressure slightly, and stimulates the vagus nerves. Toxic 
doses produce a rapid pulse from paralysis of these nerves. 

Administration.— Arnica is rarely given internally. If it is so used, 
the dose of the tincture of the flowers (Tinctura Arnica?, U. S.) is 
15 to 30 minims (1.0-2.0), and the same amount of tincture of the 
root {Tinctura Arnica? Radicis) may be employed. The plaster 
(Emplastrum Arnica?) is useful in external applications. 

The tincture of arnica is the preparation usually applied to sprains 
and bruises, and the alcohol contained in this preparation accom- 
plishes a large part of the good achieved. 

The only British preparation is the tincture (Tinctura Arnica? 
florum), which is given in the dose of 30 minims to 1 dram (2.0-4.0). 

ARSENIC. 

Arsenic (Arsenum) itself is never employed in medicine, but it is 
used in the form of arsenic trioxide (arsenous acid) or as the arsenate 
of sodium, arsenite of potassium, or arsenate of copper. When a 
physician speaks of giving arsenic to a patient he usually refers 
to arsenic trioxide. 

Arsenic trioxide (Arseni Trioxidum, U. S.; Acidum Arseniosum, 
B. P.) is derived from arsenic-bearing ores by roasting them in a 
reverberatory furnace, when it rises in the form of a vapor which 
adheres to the walls of the furnace, requiring a second sublimation, 
owing to the first deposit being quite impure. It should contain not 
less than 99.8 per cent, of pure Arsenic Trioxide and occurs as a 



118 DRUGS 

heavy solid occurring either as an opaque, white powder, or in irreg- 
ular masses of two varieties: one, amorphous, transparent, and color- 
less, like glass; the other, crystalline, opaque, and white, resembling 
porcelain. Frequently the same piece has an opaque, white, outer 
crust enclosing the glassy variety. Contact with moist air gradually 
changes the glassy into the white, opaque variety. Both are odorless 
and tasteless. 

In cold water both varieties dissolve very slowly, the degree of 
solubility varying according to conditions and time, the glassy variety 
requiring about 30, the porcelain-like or crystalline powder about 100 
parts of water at 25° C. (77° F.). Both are slowly but completely 
soluble in 15 parts of boiling water. In alcohol, Arsenic Trioxide 
is but sparingly soluble, but it is soluble in about 5 parts of glycerin. 
Oil of turpentine dissolves only the glassy variety. Both varieties 
are freely soluble in hydrochloric acid, and in solution of alkaline 
hydroxides and carbonates. 

Physiological Action.— The effects produced in man by poisonous 
doses will be found considered under the heading of Poisoning. 

Applied to the normal skin, arsenic trioxide produces no change 
of any moment, but if the surface be broken or a wound or sore exist, 
its action is very powerful, and it destroys the tissues to a consider- 
able extent. For this reason it has been employed as a caustic 
by "quacks" and to some extent by regular physicians, the latter 
using it to remove warts, condylomata, and similar growths, while the 
former have employed it chiefly as a "cancer cure," asserting that it 
would take the disease "out by the roots," which is, of course, untrue. 
Nervous System.— In medicinal amounts the drug probably acts 
as a stimulant to the trophic nervous apparatus. 

Circulation.— In moderate amounts arsenic has little or.no influ- 
ence upon the circulation. Large doses cause marked decrease in 
the force and frequency of the pulse, accompanied by a decided fall 
in arterial pressure, and in these amounts it is to be regarded as a 
distinct cardiac depressant which depresses all the heart's component 
parts, such as the ganglia, muscle, and nerves. The fall of the arte- 
rial pressure is due to vasomotor depression with relaxation of the 
general bloodvessels, more especially those of the abdominal cavity. 
According to Lesser, small doses act as a cardiac stimulant. Arsenic 
is absorbed by the bloodvessels and by a process of osmosis. 

Respiration.— In small amounts aresenic very distinctly stimu- 
lates the respiratory centers, and Lesser asserts that small doses 
stimulate the peripheral ends of the vagi in the lungs, but that in toxic 
quantities arsenic acts as a powerful respiratory depressant. 

Absorption, Elimination, and Retention.— When arsenic in 
any of its soluble forms and in medicinal or moderately poisonous 
dose enters the body by way of the alimentary canal, or through a 
break in the skin, or by way of the lungs, it is speedily absorbed and 
distributed to all parts of the body by the blood and lymph. The 
rapidity of its absorption depends upon the activity of the circulation 



ARSENIC 119 

in the part with which it comes in contact, and when it is taken by 
the mouth upon the quality and quantity of the food and drink which 
may be present in the stomach. If these are considerable in amount, 
its absorption is of course delayed, as is also its local effect upon the 
mucous membrane. When brought in contact with the tissues in con- 
centrated form, it acts so powerfully that it may destroy them and so 
for a time at least prevent its own absorption because the bloodvessels 
and lymph channels are prevented from carrying their normal fluids. 

When the dose is medicinal or slightly toxic, the drug is eliminated 
chiefly by the kidneys, although it escapes to some extent by all the 
secretions, such as the bile, the sweat, the saliva, and even in the milk 
of nursing women, and it may produce in the nursling symptoms of 
gastro-intestinal irritation by this means. The rapidity with which 
it escapes from the body after it is absorbed varies greatly in differ- 
ent persons. It does not, as a rule, appear in the urine very promptly 
after it is taken, and it continues to be eliminated over a long period 
of time in some cases. Thus, cases are on record in which it was 
found in this secretion several months after its use had been stopped. 

When a large poisonous dose of arsenic is taken by a human being, 
the greater part of its escapes from the body by reason of the vomit- 
ing and purging which it induces. It is possible for these efforts at 
elimination to be so prompt and complete that very little of the poi- 
son gains access to the general system. A large poisonous dose may 
therefore be less capable of producing death than one which is smaller 
in amount but nevertheless lethal in its effects. If the drug when 
taken in these poisonous doses is absorbed, it escapes, as it does in 
medicinal doses, chiefly by the kidneys, the feces, and by the other 
secretions named, and it is important to recall the fact that the 
amount of arsenic found in the feces does not represent alone that 
quantity which has passed through the alimentary canal unabsorbed, 
but also that it represents some of the poison which has entered the 
general system, because the liver and gastro-intestinal mucous mem- 
brane eliminate the drug by this pathway. 

During the time the arsenic remains in the body after absorption 
it is deposited chiefly in the liver and in the kidneys, in the walls of 
the stomach and bowels, and even in the muscles and bones. It has 
also been stated that it is deposited in the white matter of the brain 
in quantities which are considerable. When seeking for arsenic in a 
case of suspected death from this cause, it is important to examine 
the bones, because in some instances the drug is found in them 
after it is no longer to be found in other organs. It is from these 
"storehouses" of arsenic that eliminating organs obtain their daily 
supply for elimination. Arsenic is so rapidly eliminated in some 
cases of fatal poisoning that only a trace of it can be found on 
chemical analysis after death. (See also Poisoning by Arsenic.) 

Tissue-waste.— According to Chittenden and Cummins, arsenic in 
medicinal amount distinctly decreases tissue-changes. Large doses, 
however, greatly increase nitrogenous metamorphosis. 



120 



DRUGS 



Therapeutics.— Arsenic is used in chorea, in which it is often most 
efficient, acting in an unknown manner. The dose should be 
increased rapidly, as patients soon get accustomed to the drug, and 
large doses are essential to produce a cure in most cases. Cases are 
on record, however, in which the continued use of large medicinal 




Fig. 12. — A case of typical splenomedullary leukemia in which under the effects of 
arsenic the spleen decreased in size more than one-half, as shown in outline, and the 
white cells dropped from 342,000 to 32,000. There was a gain in weight of twenty 
pounds. 



doses has developed arsenical neuritis or renal irritation. As a tonic 
combined with iron it is invaluable in simple anemia, malarial anemia, 
and cachexia. In atony of the mucous membrane of the stomach and 
intestine it is exceedingly useful, and in ordinary anemia and debility, 
combined with a simple bitter tonic, it is invaluable. Arsenic is of 
value, too, for the improvement of depraved mucous membranes of 



ARSENIC 



121 





© 




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330,000 


















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320.000 




































315,000 


















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310,000 




















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305.000 


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300.000 
290.000 






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275,000 




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270,000 




































265,000 




































260,000 






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255,000 




































250,000 
















1 






















215,000 






































210,000 






































235,000 












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230,000 








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l 


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225,000 








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220,000 
















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205,000 








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200,000 






























195,000 




































190,000 




































185,000 


































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170,000 








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20,000 


















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Fig. 13. — Chart showing the decrease in the number of the white blood cells each 
time a patient suffering from splenomedullary leukemia received ascending doses of 
arsenic and had rest in bed. 



122 



DRUGS 



the respiratory tract, particularly in those persons who have not 
true tuberculosis, but phthisical tendencies; and in individuals who 
continually have colds in the head, chest, or elsewhere. Arsenic 
offers the best chance of benefiting cases of pernicious anemia, but 
how it acts is now known. In leucocythemia and pseudoleukemia 
arsenic is again the remedy, and it must be constantly given up to 
the point of intolerance to be of value (Figs. 12 and 13) . In the latter 
disease good results have followed its use when intraglandular and 
intrasplenic injections of 4 minims (0.25) of Fowler's solution were 
used, and a case of severe anemia, in which the stomach is disordered, 
may be treated by giving by the rectum in starch-water three times 
the ordinary dose by the mouth or by its use hypodermically in the 
proportion of 4 parts of water to 1 of Fowler's solution. (See Sodium 
Cacodylate.) 

In malaria arsenic acts as a prophylactic, as a cure, and as an aid to 
convalescence. It probably acts chiefly by increasing vital resistance 
rather than by any direct effect on the parasite. When the attacks 
of intermittent fever occur at long intervals arsenic is useful as an 
antiperiodic, quinine being withheld for use during the attack itself. 
(See Arsphenamine.) 

No drug is so universally abused as is arsenic in the treatment of 
skin diseases: it should never be employed in "wet" skin diseases; 
that is, those associated with much proliferation of new cells and the 
exudation of serum. Its field of usefulness is in the dry, scaly skin 
affections. 

When the skin is affected in its lower layers arsenic is useless, and 
should be used only when the epiderm is diseased (Duhring). 

In psoriasis arsenic at first makes the skin more red and seemingly 
worse, but this passes off and the patient gets well. This is import- 
ant to remember, as otherwise the drug may be stopped just when 
doing good. Pemphigus, lichen and lepra all yield to its influence in 
many instances. 

In the treatment of diabetes and pruritus vulva? the drug is said to 
be of value when given internally. In gouty diabetes the use of the 
carbonate of lithium and the arsenate of sodium is often of service. 

In asthma, particularly when the mucous membranes are at fault, 
arsenic is one of the best remedies that we have, either given internally 
or smoked in arsenic cigarettes, which are to be made as follows: 1 



1$ — Belladonnse foliorum 

Hyoscyami foliorum 

Stramonii foliorum 

Extracti opii . 

Tabaci .... 

Squae .... 
Fiat solutio et adde 

Potassii nitratis . 

Potassii arsenitis . 
Bibulous paper is to be wetted wi 
up and smoked as a cigarette. 



gr. xcvi (6.4) 
gr. xlv (3.0) 
gr. xlv (3.0) 
gr. iv (0.25) 
gr. lxxx (5.3) 
Oj (480.0).— M. 



gr. clx (10.6) 
gr. cccxx (21.3). — M. 
h this compound, and after drying is to be rolle 



Philadelphia Hospital Pharmacopoeia. 



ARSENIC 123 

A more simple procedure is to wet bibulous paper in a solution of 
arsenite of potassium of the strength of 15 grains to the ounce, dry it, 
and smoke it in the form of a cigarette. 

In chronic rheumatism arsenic is a very valuable tonic in certain 
cases, but often fails to be of service. In chronic coryza, in cancrum 
oris, severe sore-throat, and chronic nasal catarrh it is to be employed 
internally, and in some cases of hay fever undoubtedly affords relief. 
The use of arsenic in all stages of phthisis often gives the most sur- 
prising results. In gastric cancer and ulcer, given in small amounts 
frequently repeated, arsenic will often do good by relieving the pain 
and checking the vomiting through its tonic influence on the gastric 
mucous membrane. It may be tried in the vomiting of pregnancy 
with some chance of success, and is often of value in the vomiting of 
hand-fed babies who are suffering from chronic gastric catarrh. It 
is also useful in the morning vomiting of drunkards. In atonic dys- 
pepsia associated with chronic diarrhea and with a tendency to dys- 
entery arsenic trioxide is of service, and in small amounts it is very 
valuable in frequently repeated doses { T ~u grain [0.0006] every hour) 
in all forms of serous diarrhea. 

For gastric atony or torpidity the following prescription is useful, 
but if irritation of the stomach is present it should not be employed : 

1$ — Liquoris potassii arsenitis f oi (4.0) 

Tincturae nucis vomicae f5J (4.0) velf3ij (8-0) 

Aquas q. s. ad f giij (90.0).— M. 

S. — Shake the bottle. Teaspoonful (4.0) t. i. d. in water after meals. 

R— Arseni trioxidi gr. f (0.02) 

Ferxi reducti gr. x (0.65; 

Extracti nucis vomicae gr. iv (0.24). — M. 

Fiant pilulae Xo. xx. 

S. — One t. i. d. after meals. 

In old persons whose feet become swollen and hot after prolonged 
standing, and who have shortness of breath on exertion, arsenic does 
good, particularly if the cause be cardiac feebleness, when it increases 
the efficacy of digitalis or strychnine so greatly as to be generally 
indicated when these drugs are given. 

Locally applied to icarts and other growths of the skin for several 
days in the form of Liquor Arsenicalis (B. P.) or Liquor Acidi Arsenosi 
(U. S.) or of Fowler's solution, it causes the growth to drop off or 
to become loosened. Where the growth is very hard and horny, 
its surface should be softened by the application of potassii hydroxidi 
before the arsenical liquor is applied. The same treatment may be 
used for corns. 

Where large malignant growths with extensive surfaces are to be 
attacked locally, the physician must use arsenic most boldly or not at 
all. The danger of absorption is escaped only when the drug is used 
so freely as to destroy the tissues before they can carry on any 
absorption of the poison. A very large area should not be treated 
at one time. Marsden recommended the use of 1 ounce (30.0) each 



124 DRUGS 

of arsenic trioxide and powdered gum acacia to 5 drams (20.0) of 
water as an application to epitheliomatous growths. A less painful 
application because of the anesthesia caused by orthoform, is as 
follows: 

3— Orthoformi 5j (4.0) 

Arseni trioxidi 5j (4.0) 

Alcoholis fgv (150.0) 

Aquae destillatse fgv (150.0) 



Still another is: 

J$ — Arseni trioxidi 
Pulveris acacise 
Cocainffi hydrochloridi 
Glycerini .... 
Aquae destillatse . 

M. ft. paste. 

S. — Apply locally. 



gr. lxxv (5.0) 
gr. lxxv (5.0) 
.gr. xxx (2.0) 
lUxxx (2.0) 
q. s. 



The Marsden paste should be applied to the thickness of about 
one-quarter of an inch, overlapping the edges of the sore, and then 
covered with patent lint. The application is continued from twenty- 
four to forty-eight hours, and then a poultice is applied and the 
slough removed after from five to ten days. 

Administration.— Children generally bear arsenic better than adults, 
proportionately, but Ringer states that boys bear less than girls. 
The drug should be given before meals if it is designed to act on 
the stomach as a tonic, but in other conditions it should generally 
be administered after meals, as it is apt to irritate the stomach if 
given in full doses when this viscus is empty. Whenever a patient 
is given arsenic, he should be cautioned to watch for any puffiness 
about the eyes, particularly in the morning on arising, and for slight 
laxity and griping of the bowels. These are signs that the drug 
should be stopped for several days. The swelling under the eyes 
may spread if the use of the drug is persisted in, and finally amount 
to general anasarca. This is due at first to a cellulitis, and afterward 
to a true effusion. (See Untoward Effects.) 

It is important from a medico-legal point of view to bear in mind 
the fact that arsenic is one of those drugs to which it is possible to 
induce tolerance. That is to say, by the prolonged and gradual 
administration of arsenic in ascending doses individuals can finally 
take very large quantities with apparent impunity. Cases are 
recorded in which as much as 7 grains could be taken at one dose 
without any evil effects. 

The official preparations are: Arseni Trioxidum, U. S.; Acidum 
Arseniosum, B. P., the dose of which is -£$ to 2V grain (0.0015- 
0.003)— eV to T V grain (0.001-0.004) B. P.; the solution of the arsen- 
ate of potassium (Liquor Potassii Arsenitis, U. S.; Liquor Arsenicalis, 
B. P.) or Fowler's solution, the dose of which at first is from 1 to 
5 minims (0.06-0.3)— 2 to 8 minims (0.12-0.48), B. P.-in water; 
the solution of arsenate of sodium {Liquor Sodii Arsenatis, U. S. 



ARSENIC 125 

and B. P.), or Pearson's solution, the dose of which is 1 to 5 minims 
(O.Ofr-0.3)— 2 to 8 minims (0.12-0.48) B. P.— and the solution of 
arsenous acid (Liquor Acidi Arsenosi, U. S.), the dose of which is 1 
to 5 minims (0.06-0.3). This is more irritating to the stomach than 
the other preparations. Arsenous iodide enters into Donovan's solu- 
tion (Liquor Arseni et Hydrargyri Iodidi, U. S.; Liquor Arsenii et 
Hydrargyri Iodidi, B. P.), the dose of which is 1 to 5 minims (0.06- 
0.3)— 5 to 20 minims (0.3-1.2), B. P.-given well diluted. Arsen- 
ous iodide (Arseni Iodidum, U. S., Arsenii Iodidum, B. P.) is given in 
ifo to T V grain (0.0006-0.003) - T V to | grain (0.003-0.012), B. P.— 
doses, and arsenate of sodium (Sodii Arsenas, U. S. and B. P.) in 
the dose of T ^ to T V gram (0.003-0.0006) - T V to ^ grain (0.0015- 
0.006), B. P.— and the exsiccated sodium arsenate (Sodii Arsenas 
Exsiccatus, IT. S.), dose 2F0 to -£$■ grain (0.0003-0.0015). Liquor 
Arsenici Hydrochloride is also official in the B. P. 

Untoward Effects.— If arsenic is taken in full dose by a susceptible 
person, it may cause a marked dermatitis, with a sensation of severe 
burning in the skin and sometimes herpes zoster (Fig. 14) . Pustula- 
tion may occur, and Falck asserts that an erysipelatous state may 
arise. Almost any form of skin lesion may follow its use internally 
or externally, but nearly all show irritation of the true skin. Even a 
scarlatiniform eruption followed by desquamation may ensue. In 
other cases the mucous membranes become inflamed and coryza 
may develop. (See Administration.) The prolonged use of arsenic, 
according to de Schweinitz, may produce vitreous opacities. 

Acute Poisoning.— The symptoms of acute poisoning by arsenic, 
that is, those following the ingestion of one or more large doses of the 
drug, are chiefly due to its irritating properties, but in part to the 
effects which it exercises upon the general system after it is absorbed. 
Usually within an hour after the poison is swallowed the patient 
experiences abdominal distress, a sense of constriction in the pharynx, 
esophagus, and in a short time suffers from violent abdominal pain 
with vomiting and later profuse serous diarrhea. As soon as the 
bowel has been well emptied of its feces this diarrhea becomes a 
symptom which is to some extent pathognomonic, that is to say, the 
stools become clear and may be like the so-called rice-water stools of 
cholera, containing flakes of mucous membrane floating in serum. 
These stools also appear in antimonial poisoning, but in arsenic they 
are often streaked with blood, whereas in antimonial poisoning blood 
is rarely if ever seen. The urinary flow is decreased, and it may be 
suppressed because of three factors : (a) the profuse purging drains the 
body of fluid; (b) the passage of the arsenic through the kidneys pro- 
duces an intense toxic nephritis; (c) the vomiting prevents the inges- 
tion of water. If urine is secreted it is concentrated and albuminous. 

The general symptoms associated with those just described consist 
in pains in the extremities, probably due to the abstraction of fluid 
by the purging, great general depression and collapse, with increasing 



126 



DRUGS 



feebleness of the circulation and respiration, and finally death from 
the general intoxication produced by the drug, combined with exhaus- 
tion. As death approaches convulsions or coma may develop. Very 
commonly about the third day, if the patient survives so long, an 
intermission in the symptoms appears, which will be followed by a 
return of all the symptoms, so that the physician must not give a 




Fig. 14. — Herpetic eruption along the course of an intercostal nerve due to the use 
of 16 drops of Fowler's solution three times a day. 

favorable prognosis. In this symptom (remission) the course of 
arsenical poisoning resembles phosphorus poisoning and yellow fever. 
Death generally occurs about the fourth or sixth day, and on or 
about the third day a peculiar skin eruption sometimes appears 
which may be of any character. In rare cases sudden pain, collapse, 
and death may take place within twelve hours after the ingestion 
of the poison or unconsciousness or heavy sleep, with entire absence 



ARSENIC 127 

of gastro-intestinal symptoms ensues, death speedily coming on. 
Widespread multiple neuritis may be developed if the case survives 
for several days. 

It is to be remembered that acute arsenical poisoning may resem- 
ble poisoning by any substance capable of producing intense gastro- 
intestinal irritation. The symptoms may also be closely allied to 
those of cholera morbus and Asiatic cholera, while in some patients 
the predominance of nervous twitchings and the coma may be 
confusing. 

After death from acute arsenical poisoning certain definite lesions 
are found, which are as follows: The mucous membrane of the 
stomach and bowel is reddened and inflamed, and it may be dotted 
by areas of hemorrhagic exudate. This is not due, however, solely 
to a corrosive influence of the poison, for arsenic is not, strictly 
speaking, a corroding drug, as are the mineral acids, for example. 
The epithelial lining of the alimentary canal is easily slipped off 
as if corroded, but the actual lesion consists in the degenerative 
changes produced in it and the finer bloodvessels by the poison. 
Filehne has expressed the opinion that the epithelium is primarily 
devitalized by the arsenic and then softened and digested by the 
digestive juices. There is also present a severe diffuse toxic nephritis, 
and in the lower animals and perhaps in man marked changes in the 
suprarenal bodies. A typical change always present in acute poison- 
ing when the patient lives for any length of time is fatty degeneration 
of all the viscera. 

The exact fatal dose of arsenic trioxide is unknown because the 
individual susceptibility and readiness of absorption vary greatly. 
It is generally considered that from one and one-half to two and 
one-half grains is a lethal dose. Smaller amounts than this have, 
however, caused death and much larger ones have been survived. 

Only an infinitesimal amount of arsenic may be found on chemical 
analysis in toxic cases in the liver, bones, or nervous system. (See 
Arsphenamine.) 

Treatment of Acute Poisoning.— In addition to washing out 
the stomach by the stomach-pump, applying external heat and 
stimulants, the ingestion of the proper antidotes should be at once 
employed, and the only ones of any value are the freshly precipitated 
hydrated sesquioxide of iron and magnesium oxide. (See below.) 
The first is to be prepared by the precipitation of iron from one 
of its fluid preparations by the use of an alkali. Ammonia added to 
the tincture of the chloride of iron is efficacious, but the precipitate 
has to be repeatedly washed to rid it of an excess of this irritant. 
Magnesia is a better precipitant, because it not only precipitates the 
iron, but is also an antidote itself. Monsel's solution and the so-called 
dialyzed iron may be employed in place of the tincture, but Monsel's 
salt is too irritating. Dialyzed iron is so readily precipitated that it 
needs no alkali, but may be given pure. Magnesia is a useful anti- 



128 DRUGS 

dote when given alone. Under the name Ferri Hydroxidum cum 
Magnesii Oxido the U. S. P. recognizes an antidote for arsenic; this 
is often called the " antidotum arsenici." It is prepared as follows: 
Place 40 cc of solution of ferric sulphate (Liquor Ferri Tersul- 
phatis, U. S.) with one hundred and twenty-five cc of water, and 
keep the liquid in a large, well-stoppered bottle. Rub 10 grams of 
Magnesium Oxide with cold water to a smooth and thin mixture, 
transfer this to a bottle capable of holding about one thousand cc, 
and fill it with water to about three-fourths of its capacity. When 
the preparation is wanted for use, shake the Magnesium Oxide 
mixture to a homogeneous, thin magma, add it gradually to the 
diluted Solution of Ferric Sulphate, and shake them together until 
a uniform, smooth mixture results. (See Iron, Hydroxide of.) 

After the use of the antidote emetics should be used, opium should 
be administered to allay irritation and pain, and large draughts of 
water be given to flush the kidneys and dilute the poison. In the 
later stages the danger from arsenical poisoning arises from the 
changes produced in vital organs. 

Subacute Poisoning.— When the dose of arsenic has not been large 
enough to produce death rapidly the symptoms manifested are some- 
what modified. The vomiting and diarrhea are less severe, but 
the abdominal tenderness and distress are notable. The kidneys are 
manifestly irritated by the drug, for the urine is scanty, bloody, or 
albuminous. In these cases sufficient time elapses for the secondary 
nervous lesions produced by the drug to result in outbreaks of various 
eruptions on the skin and for localized palsies due to neuritis to ensue. 
(See Chronic Poisoning.) The mouth is parched, thirst is excessive, 
the liver is enlarged and tender, and the skin hot and dry. 

Chronic Poisoning.— Arsenic very frequently gains access to the 
body in many remarkable ways. It may be taken in cheap beers 
made from glucose, which in turn has been made with sulphuric 
acid prepared from iron pyrites contaminated by arsenic. In other 
instances it is obtained from wall-papers laden with arsenical pig- 
ments; in still other instances it occurs in artisans who handle arsenic 
bearing ores in large amounts, and it is a curious fact that a common 
result in such persons is the development of a perforating but pain- 
less ulcer of the cartilaginous portion of the nasal septum. In rare 
instances the ingestion of a few large doses which usually produce 
acute poisoning has resulted in subacute or chronic poisoning because 
of slow absorption and rapid elimination. Chronic poisoning may 
ensue by the drug entering by the mouth, lungs, or skin. 

The symptoms of chronic arsenical poisoning may for convenience 
be divided into three classes, although they are not so separated 
in the patient as a rule, being often interwoven in such a manner as 
to make a diagnosis difficult. In one class we find pigmentation of 
the skin, and nervous symptoms due to inflammations of the nerves, 
such as sharp attacks of pain, tingling in the extremities, patches 



ARSPHENAMINE 129 

of anesthesia, and localized loss of motor power. Thus it not infre- 
quently happens that there develops paralysis of the extensor muscles 
of the toes or of the peroneal muscles. In other cases the flexors 
of the foot suffer chiefly, while in still others the feet escape and 
the hands are involved in the loss of power. In cases of acute 
poisoning the paralysis may appear as early as the third day, while 
in other cases it may be delayed several weeks. The anesthetic 
areas are generally confined to the extremities, and extend only to 
the first or the second joint above. Sometimes the multiple neuritis 
caused by arsenic gives rise to symptoms which resemble those of 
locomotor ataxia. 

In other cases the manifestations of irritation of the mucous mem- 
branes are the predominant symptoms associated with disturbances 
in the nutrition of the skin, so that eruptions are produced, with 
falling of the hair and the development of cachexia. When the 
poison is inhaled, violent attacks of coryza or of asthma may occur 
and chronic bronchitis ensue. 

Chronic arsenical poisoning must be differentiated from chronic 
lead poisoning and chronic alcoholism. All three of these states may 
occur simultaneously. From lead poisoning it is to be separated by 
the absence of the blue lines on the gums, by the fact that in plum- 
bism there is rarely much disturbance of sensation and that the motor 
palsy of lead commonly affects the extensors of the forearm rather 
than the muscles of the leg, as does arsenic. The history of the 
patient is also of great aid in the differentiation. It is also said to be 
a fact that muscular atrophy is more rapid in its progress in arsenic 
intoxication than in that due to lead. In lead poisoning eruptions 
and discolorations of the skin are rare. 

Alcoholic neuritis is to be differentiated from arsenical poisoning by 
the history and appearance of the patient, by the absence of disorders 
in the skin, and by the presence of mental deterioration. 

Chronic poisoning is to be treated by withdrawal from the exposure 
and by the use of iodide of potassium to aid in the elimination of the 
arsenic. The special symptoms are to be treated by the application 
of electricity, tonics, out-of-door life, and such measures as will 
improve the general condition of the patient. (See Arsphenamine.) 

ARSPHENAMINE. 1 

Arsphenamine, sometimes called "606" or, more correctly, dioxy- 
diamido-arsenobenzol dihydrochloride, is a fine yellow powder, 
readily soluble in water, methyl alcohol (1-3), and in glycerin, but 
less soluble in ethyl alcohol, and is insoluble in ether. It depends 
chiefly for its therapeutic power upon its content of arsenic. Owing 
to the fact that it is readily oxidizable it is kept in small ampoules 

1 Arsphenamine is the name of the American product whereby use of the German 
product called salvarsan is avoided. 
9 



130 DRUGS 

in a vacuum. For this reason the contents of an ampoule when 
opened should be used at once, and none of the drug saved for another 
dose, as any change in its composition makes it poisonous. Neo- 
arsphenamine is now used nearly five times as often as this, the 
original drug. (See Neo-arsphenamine.) 

Physiological Action.— Arsphenamine when first introduced was sup- 
posed to act by reason of the fact that it combined with and destroyed 
the protoplasm of certain parasites found in the blood and tissues 
without damaging the protoplasm of their host, destroying the Tre- 
ponema pallida, the spirillum of relapsing fever, and the Trypano- 
somes of sleeping-sickness. Ehrlich believed that its action is indirect 
and is of the nature of complement-fixation reaction, and stated that 
arsphenamine does not destroy the spirochete in vitro but only in 
vivo; Schamberg tells me, however, that arsphenamine does destroy 
spirochete in vitro. 

Elimination.— Arsphenamine is broken up in the body and elimi- 
nated as arsenic. When given intravenously most of the arsenic may 
be recovered from the urine within twenty-four hours, but some of 
it is retained for many days. Jesionek found it in the urine during 
the fourth week after an intravenous dose of only 0.4 gram. The 
eliminative process is even more slow when it is used intramuscu- 
larly. Its slow elimination may possess great medico-legal import- 
ance in toxicological cases. Jeanselme, Vernes, Butrand, and Bloch 
in a joint report state that the arsenic is chiefly found in the liver, 
spleen, the lungs, and the kidneys. 

Therapeutics.— The chief use of arsphenamine is the treatment of 
syphilis in all its stages, but particularly the acute form, as repre- 
sented by mucous patches, skin affections, and the chancre. When 
the disease has existed long enough to result in the destruction of 
tissue, arsphenamine cannot be expected to cause the regeneration 
of tissue which is destroyed. 

Arsphenamine may be said to have the following scope of usefulness 
and limitations:* 

1. Arsphenamine is not to be resorted to in haphazard manner, 
as we are using a tool with a very sharp edge. In the presence of 
severe, fulminating syphilis in an acute form it should always be 
used, barring extraordinary contraindications. 

2. It is to be recalled that inadequate doses of arsphenamine not 
only fail to cure the disease but also produce a strain or breed of 
spirochetes which are so immune to its effects that large doses given 
later may also fail. 

3. Given within two weeks of the initial lesion it may, if given in 
repeated doses, produce a complete cure so far as we at present 
know, although years must pass before this is determined. 

4. Given to a patient with active lesions on the penis, or else- 
where as the point of infection, and mucous patches in the mouth, 
it exerts a marvellous influence, so that these lesions speedily become 



ARSPHENAMINE 131 

sterile, sometimes after one dose, and often heal promptly. Its 
power to produce a true cure diminishes as each week goes by, and 
after secondary symptoms are well established it fails unless asso- 
ciated with mercurial injections. This is proved by the frequent 
recurrence of relapses, particularly in nervous syphilis (see No. 6) 
and in cases of gumma. In other words, arsphenamine relieves the 
symptoms of syphilis, but does not always eradicate the infection 
and the aid offered by mercury is essential. 

5. The mild lesions in the skin in the secondary stage are affected 
apparently no better by arsphenamine than by mercury skilfully used, 
but severe ulcerative lesions are affected better by the new drug 
than the old. 

6. Gummatous lesions of the skin yield better than with mercury, 
but gummata of internal organs are equally well affected by mercury. 

7. In the cases in which syphilis of the nervous system is present 
it often fails, not only because degenerative changes have occurred 
which cannot be repaired, but also because it has been found that 
arsphenamine when in the blood cannot enter the cerebrospinal fluid 
in any quantity, since the tissues do not seem permeable to it, that 
is, the cells which secrete the fluid will not allow such complex 
molecules to pass through them. It has been found that relapses 
occur in late nervous syphilis treated by arsphenamine more fre- 
quently than when treated by mercury, and that nervous symptoms 
may become accentuated by its use, probably by development of a 
Herxheimer reaction. 

8. A course of arsphenamine injections should be followed by a 
careful course of mercury in the form of gray oil or the protiodide, 
since there is no doubt that mercury does good in syphilis that 
arsphenamine cannot do. (See Mercury.) 

9. Given to a syphilitic mother it produces antibodies in the blood 
and milk, whereby a favorable effect can be produced in a nursing 
infant suffering from syphilis. 

10. Arsphenamine seems to be even more of a specific in yaws, 
trypanosomiasis, and relapsing fever than in syphilis. It is also 
useful in malaria. (See Cinchona.) 

1 1 . The so-called Wassermann reaction usually disappears under the 
influence of arsphenamine, but when a patient with a history of 
syphilitic infection of long standing gives a negative Wassermann 
reaction it is sometimes possible to produce a positive reaction by 
giving a series of small doses, that is, the drug may be used as a 
diagnostic agent. This is called "provocative dosage." It is not 
to be forgotten that a positive reaction from a provocative dose 
may not appear for from two to seven days. 

12. Brocq well says: "Whatever be the power of the new arms 
which have lately been placed at our disposal for the treatment of 
pox, the practitioner must clearly understand that the old rules of 
therapeusis have not undergone any change. He must grasp the 



132 DRUGS 

idea that his duty is first and foremost to place the organism in the 
best possible state to resist and thus minimize the virulence of the 
infection; that by a well-ordained hygiene he may reduce to a mini- 
mum the secondary manifestations and the tertiary liabilities." 

When syphilitic symptoms are urgent and no contraindications are 
present (see page 138) Ehrlich advises 0.6 gram doses given intra- 
venously at intervals of four days, but the intravenous dose varies 
with the character of the disease, the general health, the age, and 
sex. In nervous diseases due to syphilis Ehrlich states the average 
dose to be 0.2 gram (3 grains) as a maximum. In ordinary primary 
syphilis, particularly if it be severe, the maximum dose should be 
0.5 to 0.6 gram (6-10 grains). Women usually receive 0.4 to 0.5 
gram (4-7 grains); children, 0.2 to 0.3 gram (3-5 grains). So, too, 
a feeble patient should not receive more than the dose for a child. 
When the dose is repeated it is rarely given until eight days have 
elapsed, and often not for two weeks, but in rare cases it may be 
used every other day. If the reaction due to the destruction of 
the parasite is severe, the second dose should be postponed or, if 
this is inadvisable, it should be smaller. When the disease is severe 
or persistent, six to eight doses are to be given within two or three 
months. Afterward six to eight intramuscular injections of salicylate 
of mercury given at intervals of one week are advisable. This 
double treatment is to be resorted to two or three times at intervals 
of three months. Three or four good-sized doses in the presence of 
active secondary symptoms, followed by mercury, may suffice; but 
this is rarely true, and what seems to be a cure of the disease results 
in latent syphilis which ultimately wrecks the cardiovascular-renal 
tissues or manifests itself in the nervous system. Warthin, writing 
as a pathologist, emphasizes these points in these words: 

"The therapeutic lesson is evident. Promises of cure within defi- 
nite time-limits can never be safely made, and our advice as to treat- 
ment must include the possibility of treatment extended over many 
years. The syphilitic must be treated as a germ carrier. The latency 
of the infection seems to be the same in many untreated cases as in 
those receiving very good treatment. Our present-day treatment 
seems only to succeed in rendering the infection latent rather than 
in curing it. Clinical cures may not be cures at all, as shown by the 
autopsy." For these reasons the physician should always keep up 
the treatment until the Wassermann test of the blood is negative. 
At the end of a year if the blood is still negative a small so-called 
" provocative dose" is to be given. If the Wassermann is still nega- 
tive the spinal fluid should be tested and if it is negative then the 
luetin test should be used; when if this is also negative the patient 
may be considered really cured. 

If the symptoms are more advanced, as in tertiary syphilis with a 
positive Wassermann or luetin test, treatment must be continued 
for a long time with mercury. (See Mercury.) 



ARSPHENAMINE 133 

To attack the parasite in the cerebrospinal fluid or tissues Swift 
and Ellis and, since then, many others, have given arsphenamine in 
the usual way, then draw r n some of the blood from the patient's vein 
and injected the serum containing minute amounts of the drug and 
the newly formed antibodies into the spinal fluid by spinal puncture, 
thereby avoiding the danger which would be present if arsphenamine 
was directly injected by this route. When cerebrospinal syphilis is 
present it would, therefore, seem good practice, particularly in loco- 
motor ataxia and paresis, to give an intravenous dose of arsphena- 
mine or neo-arsphenamine. An hour later about 40 mils, of blood 
are taken from the arm, allowed to coagulate, and centrifugalized. 
The next day 12 mils, of the serum are diluted with 16 mils, of normal 
saline solution and heated to 56° C. for half an hour, since this heat- 
ing has been found to increase its parasiticidal properties. Lumbar 
puncture is now performed and cerebrospinal fluid withdrawn until 
the manometer shows the pressure to be about 30 mm. of mercury. 
The barrel of a good-sized syringe is attached to the needle, which 
has been left in situ, by means of 40 cm. of rubber tubing, and the 
tubing is allowed to fill with cerebrospinal fluid up to the syringe, 
thereby driving out all air. When the tube is filled up to the barrel 
of the syringe the barrel is filled with the serum already prepared, 
and by slowly and gently elevating the tube and barrel the fluid 
enters the subarachnoid space. The dose of arsphenamine is usually 
0.45 to 0.5 every two weeks until the Wassermann test when applied 
to the spinal fluid is negative. In certain cases of locomotor ataxia 
this injection may cause some pain in the legs, which is easily relieved 
by codeine or morphine. Too much cannot be expected from this 
plan, for destroyed tissues cannot be renewed. When the spirochete 
are living in the cerebrospinal tissues great improvement may ensue 
from this treatment in the early stages of tabes, but to a much less 
degree in paresis. When evidence of infection of the brain or its 
membranes is marked it is best to precede this treatment by active 
mercurial medication, since by this means the danger of Herxheimer's 
reaction is decreased. (See Untoward Effects.) It is not sufficient 
to rely upon the Wassermann reaction in the blood, as it may be 
negative at a time when the cerebrospinal fluid will give a positive 
reaction. Furthermore, the Wassermann test of this fluid may be 
negative yet the colloidal gold test may be positive. 

I have retained the above paragraph in this edition because a 
large number of practitioners still have faith in the method therein 
described, but from my own experience, and that of my colleague, 
Dercum, I am about satisfied that any benefit which accrues is largely 
due to the draining off of the cerebrospinal and not to the injection 
of the serum. Further, I have seen the injections precipitate severe 
gastro-intestinal crises. A better plan if arsphenamine is to be used 
for an effect by intraspinal injection is to take 1 cc of the solution 
if the total amount to be given intravenously is 200 cc and lay it 



134 DRUGS 

aside in a sterile test-tube while the intravenous injection is admin- 
istered. As soon as this is accomplished 25 cc of blood are taken 
from another vein by means of a sterile syringe and placed in a 
centrifuge tube of a capacity of 50 cc and containing 4 cc of a 
sterile 10 per cent, solution of sodium citrate in normal salt solution. 
The blood and solution are gently stirred to prevent clotting and 
then centrifuged for twenty or more minutes. To the clear plasma, 
even if colored by hemoglobin, T Vcc of the arsphenamine solu- 
tion above named is added and this serum, arsphenaminized in 
vivo and in vitro, is use as for intraspinal injection after it has 
been put in a water-bath at 56° C. (132.8° F.) for thirty minutes 
(Kolmer's method). The active use of mercury and iodides is also 
essential. (See Syphilis.) 

The mere presence of a positive Wassermann reaction in the spinal 
fluid is not in itself an indication for intraspinal treatment, unless 
symptoms of neurosyphilis are beginning. Indeed, the injection may, 
as already indicated, flare up lesions which are so latent as to be 
harmless and such an injection may change a plus 2 to a plus 4, 
indicating that more poison has been set free and that the changes 
in the nervous system have been, at least for a time, exacerbated. 

When Ehrlich first introduced arsphenamine his idea was to give 
one large dose to destroy the spirochete at one stroke, because it 
was feared that the microorganism might become resistant to the 
drug if exposed to the moderate effects gradually. Ehrlich's view 
has been found to be erroneous, although it holds true with suffi- 
cient force to make it inadvisable to give very small doses over long 
periods of time. 

Administration.— Arsphenamine may be given intramuscularly, sub- 
cutaneously, or intravenously, and by the rectum. The subcutaneous 
method has been practically discarded. Given intramuscularly, the 
remedy may cause pain and may produce inflammation and slough- 
ing, although this rarely occurs. It acts more slowly given in this 
way, but is less prone to cause sharp and severe general effects than 
if given intravenously. Nevertheless in the majority of cases the 
intravenous method is the one of choice. In the preparation of 
the drug for use it must be borne in mind that arsphenamine is a 
dihydrochloride of dioxydiamidoarsenobenzol, and that when it is dis- 
solved in water it forms a diacid solution. When so dissolved with 
the addition of one molecular proportion of sodium hydroxide, it 
forms a mono-acid solution. If it is dissolved in water with two 
molecular proportions of sodium hydroxide, it makes a neutral sus- 
pension of the free base. If three molecular proportions of sodium 
hydroxide are added it forms an alkaline solution, not a suspension. 
All of these forms have been used. The alkaline solution is, however, 
the best. Before opening the ampoule it should be immersed in 
95 per cent, alcohol for fifteen minutes. If any opening is discov- 
ered that ampoule should be discarded. The following table may 



ARSPHENAMINE 



135 



be used to indicate the proportions of arsphenamine and sodium 
hydroxide in 15 per cent, solution used for intravenous or intra- 
muscular use. 



Arsphenamine. . 




Official 15 per 


cent, sodium hydroxide. 


gram. 


gram. 


= CC 


corresponding 


to drops. 


0.6 .. . 


. 1.308 


= 1.14 


" 


" 23 


0.5 .. . 


. 1.09 


= 0.95 


" 


" 19 


0.4 .. . 


. 0.872 


= 0.76 


" 


". 15 


0.3 .. . 


0.654 


= 0.57 


" 


" 12 


0.2 .. . 


. 0.436 


= 0.38 


" 


8 



Into a glass cylinder of 250 cc capacity, with a ground-glass 
stopper, put from 30 to 40 cc of cold, boiled, freshly-distilled 
water 1 (for caution see Intravenous Injection, Part III), and add 




Fig. 15. — Apparatus for intravenous injection of arsphenamine. 

0.6 gram of arsphenamine. Shake thoroughly until dissolved, and 
add about 1.14 cc (23 drops) of 15 per cent, sodium hydroxide 
solution. This forms a precipitate that redissolves on vigorous 
shaking. Add enough water to make 180 to 250 cc, adding a few 
drops of sodium hydroxide solution, if need be, to keep the solu- 
tion intact. Each 30 cc of the 180 solution contains 0.1 gram of 
arsphenamine. This is for intravenous use. 

1 If the product is that of the Dermatological Research Laboratory use hot water. 
Cool before adding sodium hydroxide. 



136 DRUGS 

For intravenous injection a syringe may be used, but an apparatus 
such as is commonly employed for the intravenous injection of normal 
salt solution is much better. (See Fig. 15.) The injection should 
be given very slowly over a period of eight minutes, while the patient 
is lying down, through a large hollow needle (No. 16 or 18) or a small 
cannula, which is pushed into a vein. Care must be taken that the 
fluid does not escape into the perivenous tissues, as it will cause great 
pain. To avoid such an accident it is best to run in some plain 
normal saline solution first, so as to be sure the needle is in the vein 
and, in order that none of the arsphenamine may remain in the vein 
when the injection is finished, it should be followed by a little saline 
solution. 

A number of material modifications of this plan have been intro- 
duced designed to simplify the technique. Thus 0.6 gram of arsphen- 
amine is placed in 10 cc of sterile distilled water, then shake the 
mixture vigorously until complete solution takes place. When solu- 
tion is absolute, add 19 drops of the 15 per cent, sodium hydroxide 
solution which causes precipitation which redissolves on shaking. 
Enough sterile distilled water is now added to make up 15 cc. If 
the solution is not clear add one more drop of sodium hydroxide 
and shake well. If after three minutes the solution is not complete 
repeat this procedure. Now draw the solution into a 20 cc Luer 
syringe. Insert needle into vein so that the appearance of blood 
proves that the vessel has been entered, expel all air from the syringe 
and inject slowly over a period of several minutes. This method 
permits the use of syringe and avoids the ill effects sometimes induced 
by large injections, but if this plan is followed the injection should 
take fifteen or twenty minutes. Even so, this is not as safe as the 
dilute solution, and Schamberg, so well known for his work in these 
lines, believes the best proportion is 20 cc of water to each 0.1 of 
drug. 

The use of freshly distilled sterile water as just described is gen- 
erally employed but it has been shown by Kolmer that sterile saline 
solution is better since a solution so prepared is less prone to pro- 
duce hemolysis. The strength of the saline solution must vary with 
the quantity of fluid used because the object sought is to inject a 
fluid which is isotonic with the blood and tissues. Thus, if the dose 
of arsphenamine is 0.6 in not less than 125 cc it may be dissolved 
in sterile normal saline, or if the dose is 0.4 in 80 cc. On the other 
hand, if the physician wishes to use a small bulk of fluid as described 
above he should use a saline solution of from 0.3 to 0.5, since if nor- 
mal saline of 0.9 per cent, is employed the necessary addition of 
sodium hydroxide will make the mixture hypertonic. As all solu- 
tions of arsphenamine are somewhat hemolytic the use of such iso- 
tonic fluids as just described are advantageous since thereby we 
avoid the hemolysis due to hypertonic injections. 

Comparatively recently the Lowy Laboratory of Newark, N. J., 



ARSPHENAMINE 137 

have marketed a practically permanent solution of arsphenamine in 
sealed glass containers holding 0.4 in 80 cc and 0.6 in 120 cc respec- 
tively. This container is directly attached to the tube and needle 
provided, and the injection given without the trouble of preparing 
the solution by the physician. 

Before arsphenamine is used by the intravenous route the patient 
should have the bowels well purged and have an empty stomach. 
He should be lying down when it is given. 

Before the injection is given the skin at the site of operation 
should be sterilized by 2 per cent, tincture of iodine. After all 
injections the patient should remain recumbent for several hours. 

Another method, involving the use of almond oil, olive oil, or 
liquid petrolatum, permits the injection to be given intramuscu- 
larly. Place a small amount of sterilized almond oil in a clean, dry 
and cool mortar and add the arsphenamine to it gradually, with 
active trituration with a pestle, so that the resulting mass is per- 
fectly smooth. This mixture when of the proper consistency to 
permit its use is drawn up into a strong syringe, the barrel of which 
must be first wiped dry and oiled. Care must be taken that none 
of the drug is left in the wound made by the needle, as it may cause 
a slough. This can be avoided by injecting deeply and being sure 
that the needle is well emptied by an energetic push at the end of 
the injection. If possible the physician should use the sterile sealed 
ampoules now placed on the market containing arsphenamine sus- 
pended in fat instead of attempting to use the plan just given. 
For intramuscular injection a strong glass syringe and a strong 
needle of No. 20 gauge should be used. The area for an intra- 
muscular injection should be two inches outward from the union of 
the folds of the buttocks. (See Salicylate of Mercury.) 

When intravenous injections are inadvisable or difficult arsphena- 
mine may be given by the rectum. The drug is dissolved as described 
above in 100 cc of water and the solution allowed to slowly enter 
the bowel. The dose should be retained as long as possible and to 
aid in its retention rest in bed should be insisted upon. The quan- 
tity of the drug used is commonly 0.6 gram, and if the patient is a 
child the dose is calculated on the basis of about 0.1 gram for each 
twenty-five pounds of body weight. The method is not as efficacious 
but is less dangerous than the intravenous plan. 

Intravenous medication is, however, almost universally resorted to. 

Untoward Effects.— Aside from severe pain, chills, or sick stomach 
which sometimes ensue after the injection of arsphenamine, suppression 
of urine and even death has followed its use, but these accidents have 
been usually in cases suffering from renal disease. Sometimes these 
symptoms are due to the use of water which has not been distilled 
just before it is used. In other cases it is due to the drug. When it 
develops after the second, or later, doses are given it seems to be a 
species of anaphylaxis. (See Antitoxin.) In these cases the symp- 



138 DRUGS 

toms are respiratory, cardiac, and of a suffocative type. Should 
pallor, chill, or emesis occur, the injection must cease. There may 
be for a time marked reddening and congestion of the local lesions, 
and under the term " Herxheimer's reaction" is described an increase, 
or darkening, of the syphilitic eruption in the first twelve hours 
after the injection. 

Sometimes two to four days after an injection there develops 
dizziness, deafness, and a stuporous state which in nervous syphilis 
may amount to unconsciousness. These symptoms may be con- 
sidered a form of Herxheimer's reaction in that the destruction of 
the parasites sets free their toxic content and this in turn causes 
irritation and possibly swelling of the nervous tissues. In others 
these symptoms develop at once after a second injection. Ehrlich 
has pointed out that to repeat the dose within four or five days in 
such instances is equivalent to pouring oil on a fire and may cause 
the death of the patient, and if a marked dermatitis develops Fordyce 
insists that it is very dangerous to repeat the dose within six months 
or a year. In those cases in which severe symptoms develop in a 
few hours after a dose and consist of meningeal irritation, jaundice, 
or evidence of renal inadequacy or inflammation, the patient is 
probably suffering from arsenical poisoning because he has an undue 
susceptibility to arsenical preparations. Ehrlich believes that in 
delayed toxic cases the symptoms may be due to an oxidation product 
of arsphenamine, paraminophenylarsenoxide. In other instances it 
is due to a deficient secretion of adrenalin. He advises that large 
doses of this substance be given hypodermically when diarrhea, 
suppression of urine, cyanosis, or coma follow the use of arsphena- 
mine and asserts that adrenalin will save desperately ill patients. 

In some cases jaundice due to the drug does not develop for several 
weeks, or even after several months. It may be mild or severe and 
run a rapid course to death, resembling cases of acute yellow atrophy 
of the liver. 

Contraindications.— Arsphenamine is contraindicated in advanced 
degenerative lesions of the nervous system or kidneys, in advanced 
tuberculosis, when there is disease of the nervous portion of the 
auditory apparatus, and in persons who have a marked idiosyncrasy 
to arsenic. 

Arsphenamine must be used with the greatest caution, or not at 
all, in the presence of marked myocarditis. So, too, in acute cerebral 
syphilis it must be used with care lest it produce an acute exacerba- 
tion by intensifying the inflammatory process already present. Such 
cases should first receive a thorough course of mercury and iodides. 
(See Untoward Effects.) Addison's disease contraindicates this drug, 
as does also status lymphaticus. 

Under the name of salvarsan natrium or sodium salvarsan, Ehrlich 
shortly before his death introduced a preparation 1206 A. This 



ASAFCETIDA 139 

preparation is now used in this country under the name sodium 
arsphenamine. It has the advantage in its preparation for injection 
of being soluble in water without the addition of sodium hydroxide, 
but as 3 parts of it are equal to 2 parts of arsphenamine in arsenic 
content and therapeutic efficiency it is not so useful unless the dose 
is increased over that of the original product. Nevertheless it is 
rarely given in excess of 0.9. As soon as the ampoule is opened it 
must be added to sterile distilled water at once in the proportion of 
20 cc of water to each 0.1 gram of drug. The solution must not be 
heated and it must not be violently shaken lest the drug be oxidized. 
After the solution is made it must be used at once. If a perfect 
solution should not form discard that sample. 

ASAFCETIDA. 

Asafcetida, U. S., Asafetida, B. P., is a gum resin obtained by mak- 
ing an incision into the root of Ferula foetid a. It occurs in irregular 
masses of a dark-yellow or reddish color, which become still more 
red if exposed to the light and air. Asafcetida in tears is a term 
applied to the drug when it appears in the shape of drops or pearls, 
and is a form seldom seen. Its odor is penetrating and strong, and 
resembles that of garlic. When taken internally, it causes a sensa- 
tion of warmth and acts as a stimulant and carminative in the 
alimentary canal. 

Therapeutics.— Asafcetida is used in medicine as a carminative 
which w T ill particularly affect the lower bowel, and is useful in the 
intestinal indigestion of old persons when associated with flatulence, 
and in the flatulent colic of children. In the form of rectal injections 
it is of value for relief of the tympanites of children and in that of 
adults during typhoid fever and pneumonia. It is also used as a stimu- 
lating expectorant in the later stages of bronchitis. In the nervous 
irritability of children it is often of service. 

Administration.— Asafcetida is given in pills of asafcetida (Pilulce 
Asafoetidoe, U. S.), of which 2 or 3 may be taken, each one con- 
taining 3 grains (0.2) ; the emulsion or milk of asafcetida (Emulsum 
Asafoetidas, U. S.), the dose of which is \ to 1 ounce (16.0-30.0); and 
the tincture (Tinctura Asafoetidce, U. S. and B. P.), § to 1 fluidram 
(2.0-4.0). The suppositories at one time official contained the 
equivalent of 40 drops (2.6) of the tincture. The plaster of asa- 
fcetida (Emplastrum Asafcetida) is used where a mild counterirritant 
and antispasmodic is needed. When intestinal indigestion and flatu- 
lence occur in old people, the following pill is of service: 

1$ — Extracti nucis vomicae gr. v (0.3) 

Pulveris capsici gr. xx (1.3) 

Asafcetidse gr. xl (2.6).— M. 

Rant pilulse No. xx. 

S. — One night and morning. 



140 DRUGS 

A B. P. preparation, not official in the U. S. P., is Pilula Galbani 
Composita, composed of asafcetida, galbanum, and myrrh; dose 4 to 
8 grains (0.24-0.48). 

ASPIDIUM. 

Aspidium, U. S., Filix-mas, B. P., or Male Fern, the rhizome of 
Dryopteris Marginalis (or Aspidium Filix-mas, B. P.) is employed in 
medicine as a tseniacide or remedy for the tapeworm, and is a very 
efficient and valuable drug under such circumstances, being, perhaps, 
the most reliable of all the tseniafuges except pelletierin. When 
employed, the directions and precautions given in the article on 
Worms (Part IV) must be strictly followed. It is also a valuable 
remedy in uncinariasis. 

Male fern taken in overdose is capable of producing poisoning, 
and when taken in such a dose causes, according to Quivill, irritation 
of the gastro-intestinal mucous membrane and diarrhea. If absorbed, 
it acts on the central nervous system and causes paralysis, collapse, 
and death. The form and manner by which it is eliminated are 
unknown. It may in overdose cause albuminuria and glycosuria. 
To give more than 1J drams (6.0) of the oleoresin at a dose is 
dangerous. 

Administration.— Male fern is rarely, if ever, used at present in 
its crude form, being employed most commonly in the United States 
in the form of the oleoresin (Oleoresina Aspidii, U. S.); dose J to 1 
fluidram (2.0-4.0) in capsule, or as follows: 

1$ — Oleoresinse aspidii, 

Tincturse vanillse aa Tl\xlv (3.0) 

Pulveris acacise 3ss (2.0) 

Aqua? destillatse fgj (30.0).— M. 

S. — Take entire amount after fasting, and follow in two hours by a full dose of 
sulphate of magnesium. 

Another useful formula is as follows: 

1$ — Oleoresinse aspidii f'5ij (8.0) 

Fluidextracti kamalse f3ij (8.0) 

Chloroformi TTU (0.65) 

Olei tiglii TTIJ (0.06) 

Oleiricini q. s. ad f 5 i J (60.0).— M. 

S: — After a purgation with calomel and a saline purge give one-half of this, and 
give the second half two hours later. 

The dose of the liquid extract (Extractum Filicis Liquidum) of the 
B. P. is 45 to 90 minims (2.7-5.4). 

Katamaya and Okamoto, two Japanese investigators, and Poulssen, 
state that castor and other oils should not be used after filix-mas is 
given, as oils increase the absorption of the active principle, and so 
predispose to the development of poisoning. 

ASPIRIN. 

Aspirin is acetyl-salicylic acid (Acidum Acetylsalicylicum, B. P.), 
and occurs in white crystalline needles which melt at 135° C. and 



AZEDARACH 141 

is soluble in 300 parts of water. It is readily dissolved in alkaline 
fluids. Owing to its chemical constitution, aspirin has been intro- 
duced into medicine as a substitute for the ordinary salicylates; 
and as it is dissolved and absorbed in the bowel, as is salol, it is said 
not to irritate the stomach. Unless well diluted, however, it causes 
gastric distress. It is not so disagreeable to the taste as are most 
of the salicylate preparations, and it is claimed is less likely to cause 
tinnitus. The dose of aspirin as a remedy for acute rheumatism is 
10 to 15 grains (0.65-1.0) four times a day or oftener. It is also used 
in lithemic or gouty states in place of the older salicylates. It may 
also be employed as an intestinal antiseptic. Its most general use, 
however, is for the relief of neuralgic pain. Aspirin may be applied 
by means of dipping an applicator covered with wet cotton in the 
finely powdered drug, with excellent results in the early stages of 
tonsillitis. The applications should be made every six hours. 

This preparation is now made in America and there is no need of 
prescribing it except under the official British name. (See Nov- 
aspirin.) 

ATOPHAN. 

This substance is official under the name Acidum Phenykinchon- 
inicum and is made in America under the name Cinchophen. It is 
an almost colorless, tasteless, crystalline powder, insoluble in water, 
but readily soluble in alkalies or hot alcohol. A number of investi- 
gators have proved that it greatly increases the elimination of uric 
acid and it undoubtedly relieves pain in gouty and lithemic persons, 
but that it is directly useful in the cure of gout is undecided, for gout 
is something more than the mere formation and retention of uric 
acid in excess. The increase in the elimination of uric acid is, how- 
ever, due chiefly to the action of the drug on the kidneys. It does 
not mobilize deposited urates. 

Atophan is best given in tablets or capsules, or powder stirred 
in water after meals and at bedtime being washed down with a full 
draught of water, preferably Celestin Vichy water, or water contain- 
ing sodium bicarbonate. The ordinary single dose is 7 to 10 grains 
(0.5-0.65). 

AZEDARACH. 

Azedarach is the bark of Melia Azdarach, or Pride of China, as 
it is sometimes called. It is found in Syria, Persia, the north of 
India, and in the Southern United States. 

The berries have but little toxic power, and children may eat of 
them largely without ill effect, but the bark is poisonous when taken 
in overdose, and produces symptoms resembling those of poisoning 
by spigelia or belladonna. It is employed as a remedy for the rowid- 
worm, and should be given in decoction made by boiling 2 ounces 



142 DRUGS 

(60.0) of the bark in 1 pints (720 cc) of water until only a pint 
(480 cc) of liquid remains. Of this, from 1 to 2 tablespoonfuls 
(16.0-30.0) are to be given a child, and repeated every two hours 
until the bowels are opened. It has also been used as a fluidextract 
prepared by the ordinary means with alcohol, to which some white 
sugar should be added. The dose of this fluidextract is a teaspoon- 
ful (4.0), and it is not to be repeated. The decoction is the best form 
in which to use the drug. 

BALSAM OF PERU. 

(Balsamum Peruvianum, U. S. and B. P.). A balsamic exudate 
from Toluifera Pereirce, is a viscid liquid of a dark brown color, agree- 
able odor, bitter acrid taste, producing a burning sensation in the 
throat, soluble in absolute alcohol, chloroform, and glacial acetic 
acid, and only partially soluble in ether and alcohol. Internally it 
has been employed as a stimulating expectorant. Externally it is 
commonly used in healing salves. One dram (4.0) of balsam to 7 
(28.0) of simple cerate is useful in the healing of cracked nipples 
and indolent ulcers. Mixed with vaseline and rubbed over the 
hands it prevents disagreeable odors remaining on the skin after 
treating ulcerative surfaces or making postmortem examinations. 
Applied over a large area of the body as a remedy for scabies it may 
cause acute nephritis. 

BARBITAL AND BARBITAL SODIUM. 1 

Barbital, German name Veronal (Barbitonum, B. P.) is a com- 
pound of urea, its chemical name being diethylamalonylurea. It 
occurs in fine white, crystalline powder, which is odorless and has a 
faintly bitter taste. Barbital is soluble in 145 parts of water and 
for this reason is always given in capsule or cachet. Its action is 
allied to that of trional and it is said to have no effect upon the 
blood or respiration. 

It is used to produce sleep, to a limited extent as a pain reliever, 
and is commonly given in capsule in the dose of from 5 to 10 grains 
(0.3-0.6) taken half an hour before retiring for the night. The drug 
is prone to lose its effect if given continuously for more than two 
weeks. When given for a long period the bowels must be kept freely 
open and alkalies administered. It is a most satisfactory hypnotic 
in nervous insomnia and is singularly free from after-effects. When 
taken in full dose it will often cause ataxia, hallucinations and tremor. 

Very large doses of barbital are necessary to produce death, prob- 
ably more than 150 grains. When a poisonous dose is taken sleep 

1 As veronal and medinal are familiar terms, reference is made to them at first 
impulse, but physicians should use the American terms barbital and barbital sodium, 
as by so doing they use American-made drugs. 



BELLADONNA 143 

lasts about two or three days, and rarely sleep lasts for ten days. 
The heart and respiration act normally in the mild cases, and pupil- 
lary reactions are maintained. When a lethal dose is injected the 
action of the heart and respiration become irregular, Cheyne-Stokes 
breathing develops and cyanosis ensues, followed by death, usually 
not for at least twenty-four hours. 

Under the name of Barbital Sodium, German name Medirial, a 
soluble salt (1 to 5 of water) of barbital has been introduced, which 
can be given in solution by the mouth or rectum. When used hypoder- 
mically 7 grains (0.5) are dissolved in 75 minims (5.0) of distilled 
water. The dose is the same as that of barbital. Barbital Sodium 
also acts more rapidly when given by the mouth than does barbital 
because it is soluble. It is best administered in tablet form or in hot 
sweetened water. 

BELLADONNA. 

Belladonna is botanically known as Atropa Belladonna, and is 
official in the form of the root (Belladonnas Radix, U. S. and B. P.) and 
leaves (Belladonna Folia, U. S. and B. P.). The root should yield 
not less than 0.45 per cent, of the total alkaloids and the leaves not 
less than 0.3 per cent. Its popular name is "deadly night-shade." 
The drug belongs to a very large class of plants, namely, the 
Solanacece, all of which have a similar physiological action. Bella- 
donna contains an active principle in the form of an alkaloid known 
as atropine (Atropina, U. S. and B. P.), which is insoluble in water. 
It should be kept in well-closed containers, protected from light. 
Atropine possesses a bitter, acrid taste (it should be tasted with the 
utmost caution and only in dilute solution) . The sulphate of atropine 
(Atropine Sulphas, IT. S. and B. P.) is very soluble, and is the salt 
commonly used. 

Physiological Effects.— In man, full medicinal doses produce flush- 
ing of the face, redness and dryness of the fauces, dilated pupils, 
sometimes an erythematous rash over the skin, rarely diplopia and 
delirium. If the dose be still larger, the delirium becomes marked, 
and is wild and talkative. The pulse is rapid and wiry. The rash 
which appears resembles that of scarlet fever, but lacks the punctua- 
tions. The skin may desquamate after the lapse of several days if 
the rash is severe. 

In children belladonna is usually borne very well. When the 
action of belladonna asserts itself in children and in susceptible adults 
the respiration is quickened, the eyes become bright and the cheeks 
red, but lines of pallor reach from the malar bones to the angles of 
the mouth, giving to the face a curious expression. 

Absorption.— This drug is very rapidly absorbed. 

Nervous System.— Belladonna when given in medicinal amount 
approaching the toxic dose acts as a powerful excitant of the brain, 



144 



DRUGS 



producing talkative delirium. Locally applied, it depresses the 
peripheral sensory nerves. 

When very large doses are given to animals, paralysis of the 
spinal cord comes on, followed by tetanic spasms, and finally by 
recovery. The primary loss of power is due to paralysis of the entire 
cord, and the second state, of convulsions, to the escape of the motor 
and sensory pathways from the paralysis before the inhibitory centers 
recover. As a result, any peripheral irritation causes violent explo- 
sions of motor power. 1 Even in large medicinal dose belladonna 
may be considered as a depressant to the motor nerves and as a 
quieter to sensory nerve filaments. On voluntary muscles the drug 
has no effect, but upon unstriped muscles it acts as a sedative and 
antispasmodic. It distinctly lessens reflex action. 

Circulation.— Belladonna quick- 
ens the pulse by depression of the 
peripheral vagi and by stimulating 
the cardiac muscle and the acceler- 
ator nerves. It has been thought 
that atropine causes a rise of arterial 
pressure, but recent investigation has 
thrown doubt upon this view. That 
the drug acts as a powerful agent 
upon the vascular system is certain. 
It dilates the bloodvessels of the 
skin, but contracts the vessels of 
the splanchnic area, and this is why 
it is so valuable in collapse and 
shock, since relaxation of the 
splanchnic vessels is the dominant 
vascular state in these conditions. 
In other words, it restores circula- 
tory equilibrium. The dilatation of 
the capillaries of the skin is in part the cause of scarlet-red skin of 
belladonna poisoning. 

In poisonous doses it causes a fall of arterial pressure due to 
centric vasomotor palsy and depression of the muscular coats of 
the bloodvessels, but there is no direct cardiac depression, as has 
been generally taught, for Reichert has proved that the drug is not 
a heart-depressant unless the dose is simply overwhelming. Some- 
times when belladonna is given the pulse becomes slow, but in these 
cases the slowing is due to temporary stimulation of the peripheral 
vagi or to momentary depression of the cardiac motor ganglia. (See 
Figs. 16 and 17.) 

1 If a homely simile, found useful by the writer in teaching, may be used, the inhibi- 
tory centers may be represented by a schoolmaster and the motor and sensory centers 
by two boys. The escape of chloroform in the room paralyzes them all, but, finally, 
the boys recover before their master and go off as truants (convulsions) ; at last the 
master (inhibitory centers) recovers and order, or health, is restored. 




Fig. 16. — A, atropine depresses 
the peripheral vagi and stimulates 
the accelerator nerves (C). 



BELLADONNA 



145 



Respiration.— Atropine is a stimulant to the respiratory center 
in ordinary amounts, but recent careful studies show that its high 
reputation as a respiratory stimulant is not based either on clinical 
or experimental evidence. In many cases it fails to increase the 
respirations at all, and it is certainly inferior to caffeine and strych- 
nine in the treatment of opium poisoning. In large doses it is a 
depressant and paralyzant to respiration, and produces death from 
respiratory failure due to paralysis of the motor nerves supplying 
the respiratory muscles, and probably by depressing the respiratory 
center. 



\fViWVV^ 



ii 



in 



rv 



vWW^AAAAA^JV^^,^ 




Fig. 17. — Tracing showing the effect of atropine as a vasomotor stimulant (after 
Schmiedeberg) : I, normal tracing of pressure (126) and pulse 28 in ten seconds; 
II, pressure lowered by pilocarpine to 96, pulse 19; III, tracing continued, pressure 
70; IV, atropine has been given, raising the pressure to 145, pulse 30 in ten seconds. 



Abdominal Viscera.— Balladonna increases peristalsis by depress- 
ing the peripheral ends of the inhibitory fibers of the splanchnic 
nerves, and by diminishing any tendency to spasm on the part of the 
muscular coats of the intestine. The splanchnic effect has been 
denied. 

Action on Secretion.— The drug decreases all the secretions of 

the body except the urine, which is sometimes increased in amount 

under its use. The decrease of secretion is due to paralysis of the 

peripheral nerve-filaments supplying the secretory cells of the glands. 

10 



146 DRUGS 

Bodily Heat.— When belladonna is used in large amounts there 
is nearly always a rise of temperature, which in children may amount 
to one or two degrees. This is probably due to stimulation of the 
thermogenic center in the corpus striatum. In advanced poisoning 
the temperature rapidly falls. 

Elimination.— Atropine is eliminated by the kidneys and bowels 
with extraordinary rapidity, and this is one of the reasons why 
death from poisonous doses of the drug is so rare. J. Harley asserts 
that it is entirely eliminated in two hours, and Meuriot states that 
not a trace of it can be found after twenty-four hours, and that it is 
partly destroyed in the liver. In a case of suspected poisoning the 
urine of the patient may be dropped into the eye of an animal, 
when, if atropine or belladonna has been taken, mydriasis will 
result. 

Eye.— On the eye belladonna produces dilatation of the pupil in 
part by a depressant action on the endings of the oculomotor nerve 
in the iris, by causing a paralysis of the circular muscle-fibers in the 
iris and perhaps by a stimulant effect on the peripheral sympathetic 
nerve-fibers. The dominant action of the drug is undoubtedly the 
depression of the circular muscular fibers of the iris. Associated with 
mydriasis there is also paralysis of accommodation due to the paraly- 
sis of the ciliary muscles by the effect of the drug on the oculomotor 
nerve. Belladonna generally increases intra-ocular tension. 

Poisoning.— Poisoning by atropine is an exceedingly common occur- 
rence, but death is rarely produced by it, partly because its influence 
is not very actively exercised on vital parts, and partly because it is 
eliminated by the kidneys almost as rapidly as it is absorbed from 
the stomach. Recovery has occurred after as much as one grain of 
atropine has been taken by a child of three years. Aside from the 
symptoms of mild poisoning detailed under the heading of physio- 
logical action, severe poisoning is characterized by deep sleep, pre- 
ceded, it may be, by convulsions, violent delirium, blindness, and 
sometimes loss of speech. 

Treatment of Poisoning.— Poisoning by belladonna is to be 
treated by emetics, the application of external heat if the patient 
passes into collapse, and the use of strychnine if respiration fails. 
Opium may be employed in carefully graded doses as the physiologi- 
cal antagonist; but large doses are of doubtful service, particularly 
if the respirations are not in a satisfactory state. 

Therapeutics.— Belladonna is used to allay excessive secretion, to act 
as an antispasmodic, and to influence the circulatory apparatus when 
local inflammations are beginning, particularly in secretory glands, 
and to act as a vascular tonic (Fig. 17). In cardiac palpitation small 
doses of belladonna internally, or its external use over the precordium 
in the form of the plaster or ointment, is very valuable. 

For the relief of local nerve-pains it is of value, and probably acts 
by quieting the irritated nerve. It should be applied in these cases 



BELLADONNA 147 

in the form of an ointment or plaster, and if the ointment is used it 
should be well rubbed into the part affected.. 

To check secretion in night-sweats it is one of the most powerful 
remedies we have, and it is useful in excessive idiopathic ptyalism, as 
seen in children, or in that due to mercurialization. In bromidrosis 
of the feet and other localized sweatings it is useful, and may be 
employed locally or taken internally for their cure. It is the most 
efficacious drug we have for checking the secretion of milk in an inflamed 
breast, and under these circumstances it is to be smeared over the 
gland in an ointment. Belladonna may be used in serous diarrhea, 
as it checks the disorder by stimulation of the splanchnic filaments of 
the intestinal bloodvessels, which being inactive permit a transudation 
of liquid into the bowel. 

Trousseau recommended as a local remedy 1 to 2 grains (0.06- 
0.12) of the extract of belladonna with 6 to 8 grains (0.4-0.5) of 
tannic acid in leucorrhea dependent upon disease of the uterine cer- 
vix. This should be placed on a pledget of cotton and applied to the 
affected part daily, being allowed to remain all day. Ringer states 
that if pain is also present in these cases the following injection is of 
value. 

I^ — Sodii bicarbonatis 3J (4.0) 

Tincturse belladonna foliorum f 5ii.i (12.0) 

Aquae destillatse q. s. ad Oj (480 cc). — M. 

This is to be injected into the vagina, the woman first being placed 
on the back with the buttocks raised, so that the drug may bathe the 
uterine cervix for some minutes. 

As an antispasmodic, atropine is to be used in acute torticollis, 
injected directly into the muscle itself so as to act on its motor nerve- 
fibers; it may be given in spasm of the intestines with cramps and 
griping. In cramps in the legs and body, either as a local application 
by means of liniments or when employed internally, it is of service. 
In asthma of the spasmodic type atropine is a sovereign remedy, 
particularly if it be combined with morphine. It may be used both 
as a prophylactic and as a cure during the attack. Belladonna-leaves 
may be smoked by asthmatics by rolling them into a cigarette or 
putting them into a pipe. 

This drug is used in whooping-cough at all ages and in all stages, 
but it must be given in large amounts and is only a palliative. 

In spasm of the sphincter ani, whether it be due to fissure or other 
cause, belladonna in the form of an ointment or suppository is of 
value. In spasm of the urethra and bladder the drug may be used 
internally and externally, and in the former state the ointment 
should be smeared along the under surface of the penis every night. 
This treatment is also useful in chordee. In the colic resulting from 
the passage of hepatic and renal calculi atropine in full dose by the 
hypodermic needle combined with morphine will very often give 
relief. Where urinary incontinence depends upon spasm of the 



148 DRUGS 

bladder belladonna should be used. (See Incontinence of Urine.) 
In dysmenorrhea in nervous women, with spasm of the cervix uteri, it 
is of value applied as an ointment or in a vaginal suppository, or 
when given by the mouth. For the nervous cough of children and 
adults belladonna is one of the best remedies we have. In constipa- 
tion it does good by depressing the inhibitory nerves of the intestine. 
It is also of value in laryngismus stridulus and in hiccough. In 
children who suffer from what has been called hypertonia, a state 
characterized by irregular attacks of vomiting with visible peristalsis, 
constipation of the spastic type, muscular irritability and insomnia, 
atropine will often act as a specific. If improvement does not follow 
its use after a few doses the case is probably not one of hypertonia. 

In iritis atropine is used to dilate the pupil and prevent adhesions. 
The solution to be dropped into the eye should contain 1 to 4 grains 
(0.06-0.25) of atropine sulphate to the ounce (30.0) of water. (See 
Iritis.) Atropine sulphate is also used for the purpose of producing 
mydriasis before ophthalmoscopic examination, in solutions of the 
strength just given. It increases intra-ocular tension and is contra- 
indicated in glaucoma. 

When employed to act on the circulation, it is to be used in shock 
and collapse from injury or in the course of severe disease. (See 
Shock.) During the progress of a case of pneumonia, typhoid fever, 
or other severe disease belladonna should be kept in the house, and 
administered freely if collapse or relaxation of the splanchnic vessels 
suddenly asserts itself. Particularly is this true in the case of pneu- 
monia. The vascular system during the crisis of this disease will 
often be found much relaxed, and heart stimulants do not seem to do 
much good. The administration of atropine or belladonna will dry 
the leaking skin, and by increasing the vascular tone produce great 
improvement. A large dose of atropine, given hypodermically, is 
the best remedy we have in pulmonary edema, and for the relief of 
the symptoms of anaphylaxis after the use of antitoxin. The hypo- 
dermic use of atropine before administering chloroform greatly in- 
creases the safety of this anesthetic. (See also Scopolamine.) 

In mastitis, or inflammation of the breast, belladonna, if pushed, 
will give surprisingly good results if given internally and applied 
locally. In acute sore-throat, when there is a sensation of rawness 
in the pharynx, while the local capillaries appear injected and red, 
belladonna is often of the greatest service if given in full dose, 
aborting the "cold." 

In exophthalmic goiter belladonna certainly gives relief in some cases, 
particularly if combined with strophanthus or digitalis. 

In headache occurring in young persons, often due to ocular over- 
work, with pain in the eyeballs and forehead and a sensation as if 
the orbits were too small for the eyeballs, belladonna is of service. 
In intercostal neuralgia or pleurodynia belladonna plasters may be 
applied to the spot where the pain is felt, with relief. 



BELLADONNA 149 

Use of Atropine in Poisoning.— Atropine is a physiological antidote 
to opium, Calabar bean or physostigma, and jaborandi. In opium 
poisoning it acts as an antidote in all parts of the body except the eye, 
and in jaborandi poisoning the same holds true; but in the former 
condition, although it has been largely used, it is no longer regarded 
as a satisfactory antidote; caffeine and strychnine are preferable. 
The condition of the pupil is not a guide as to the effect of atropine 
in opium poisoning, because opium acts centrically and atropine acts 
peripherally on the nerves governing the iris. Atropine should be 
used in aconite, antimony, and hydrocyanic acid poisoning for its 
stimulating influence on the vasomotor system, the respiratory 
center, and the heart, and for the purpose of maintaining the bodily 
heat, the dissipation of which it retards by preventing vasomotor 
palsy and consequent dilatation of the peripheral bloodvessels. 

Atropine is a valuable physiological antidote to poisonous mush- 
rooms, particularly the Amanita, as it is antagonistic to their poison, 
muscarine. The dose given should be large, and, if need be, repeated. 

Administration.— The dose of the sulphate of atropine (Atropina? 
Sulphas, U. S.. and B. P.) is 21b to ^ grain (0.0002-0.0015). The 
alcoholic extract (Extraction Belladonna? Foliorum, U. S.; Extractum 
Belladonna? Siccum, B. P.) is given in J to J grain (0.01-0.015) 
doses, and the tincture (Tinctura Belladonna? Foliorum, U. S.; 
Tinctura Belladonna?, B. P.) in the dose of 5 to 40 minims (0.3-2.6), 
5-15 minims (0.3-1.0), B. P. Both these preparations are derived 
from the leaves. The extract of belladonna leaves should contain 
1.18 per cent, to 1.32 per cent. (B. P. 1 per cent.) of alkaloids. The 
tincture of belladonna leaves should contain 0.027 gram to 0.033 
gram of total alkaloids to each 100 cc. The fluidextract (Fluidex- 
tractum Belladonna? Radicis, U. S.) is given in 1- to 2-minim (0.06-0.12) 
doses, but Extractum Belladonna? Liquidum (B. P.) is given in f- to 
1-minim (0.015-0.006) doses. These preparations are derived from 
the root. The fluidextract of belladonna root contains 0.405 to 
0.495 gram of alkaloids in each 100 cc. Belladonna liniment (IAni- 
mentum Belladonna?, U. S. and B. P.), belladonna plaster (Emplas- 
trum Belladonna, U. S. and B. P.), the ointment ( Unguentum 
Belladonna?, U. S. and B. P.) are for external application. The 
preparations of the B. P. not official in the U. S. P. are Liquor Atro- 
pine Sulphatis, dropped in the eyes in the dose of § to 1 minim 
(0.03-0.06); Lamella? Atropina?, each of which contains 5-0V0 grain 
of atropine; and Unguentum Atropina? and Extractum Belladonna? 
Alcoholicum, derived from the root. Succus Belladonna?, B. P., is 
given in 5- to 15-minim (0.3-1.0) doses. There is also official in the 
B. P. a suppository (Suppositoria Belladonna?) which contains 1| 
grains of the extract. 

Contraindications.— Belladonna decreases salivary and gastric secre- 
tion very considerably in some persons. It is better, therefore, not 
to administer it just before^or immediately after a meal, unless it 
is desired to reduce gastric secretion. 



150 DRUGS 

BENZOIN AND BENZOIC ACID. 

Benzoin (Benzoinum, U. S. and B. P.) is a resinous balsam derived 
from Styrax Benzoin, which is a native of Sumatra, Borneo, and 
Java, and another unidentified species of Styrax. It occurs in 
pebble-like bodies or tears, mostly 0.5 to 5 cm. long and about one- 
fourth as thick, slightly flattened, straight or curved, yellowish- to 
rusty-brown externally, milky-white on fresh fracture, separate or 
very slightly agglutinated (Siam Benzoin), or embedded in a dry 
resinous mass, which varies from reddish-brown to reddish-gray 
or grayish-brown; opaque or slightly translucent and more or less 
lustrous (Sumatra Benzoin); brittle, becoming soft on warming, 
and yielding benzoic acid on sublimation; odor agreeable, balsamic 
(vanilla-like in the Siam variety) ; taste slightly acrid. 

Benzoin is almost wholly soluble in 5 parts of warm alcohol, the 
solution showing an acid reaction to blue litmus paper; and soluble 
in solutions of sodium or potassium hydroxide. Benzoic acid is 
obtained by the sublimation of gum benzoin, or is prepared artificially 
chiefly from toluol. The last method of preparation is not to be 
recommended, as the acid so made often disorders the stomach and 
leaves a disagreeable taste in the mouth. It is benzoic acid which is 
generally used in medicine. 

Physiological Action.— Locally applied in concentrated form, ben- 
zoic acid is an irritant, and taken internally in excessive amount it 
causes a sensation of warmth and burning. It is eliminated as hip- 
puric acid and increases the acidity of the urine. It is an antiseptic 
and germicide. In persons having an idiosyncrasy to benzoic acid it 
is not uncommon for urticaria to follow the use of the drug. Some- 
times a papular or erythematous eruption appears after its use. The 
action of this drug in the system is closely allied to that of salicylic 
acid, in that it increases metabolic changes in the tissues. It also 
decreases putrefactive changes in the intestine. 

Therapeutics.— Benzoic acid is useful in the treatment of chronic 
cystitis with alkaline urine which is loaded with phosphates, and com- 
bined with cannabis, acts well in the later stages of gonorrhea. 
Senator states that in the dose of 2 or 3 drachms (8.0-12.0) a day it 
is a specific in acute rheumatism, and thinks it equal to salicylic acid. 
When these doses are to be used, the benzoate of sodium should be 
employed, owing to its solubility. In acute laryngitis accompanied 
by great hoarseness the inhalation of steam laden with compound 
tincture of benzoin is of the greatest service. A tablespoonful (15.0) 
of this tincture should be placed in a pitcher of boiling water, the 
face held over the liquid, and a towel thrown over the head of the 
patient to retain the steam. The drug cannot be used in an atomizer, 
as it clogs the "tips." Taken internally, benzoic acid is useful as an 
expectorant in chronic bronchitis in the dose of 10 grains (0.6) three 
times a day. 



BETANAPHTHOL 151 

Administration.— The dose of benzoic acid (Acidum Benzoicum, 
U. S. and B. P.) is usually 10 to 40 grains (0.6-2.6), 5-15 grains 
(0.3-1.0), B. P., but a dram may be given in capsules. The balsam 
itself is never used as such. The tincture ( Tinctura Benzoini, U. S.) 
is given in 30-minim to 1-dram (2.0-4.0) doses, and the compound 
tincture (Tinctura Benzoini Composite/,, U. S. and B. P.), composed of 
benzoin, purified aloes, storax, balsam of Tolu, and alcohol, the 
dose of it being 1 to 2 fluidrams (4.0-8.0). The preparations 
official in the B. P., but not in the U. S. P., are the troche ( Trochiscus 
Acidi Benzoici) and Unguentum Cetacei. 

Adeps Benzoinatus (U. S.) and Adeps Benzoatus (B. P.), or ben- 
zoated lard, is a non-rancid basis for many ointments, notably that 
of zinc. 

BENZYL BENZOATE. 

Benzyl benzoate when taken into the body is so affected by its 
metabolic processes that the benzyl radical is set free. This benzyl 
radical possesses properties closely allied to those of papaverine, one 
of the alkaloids of opium, but without its narcotic effects, namely, the 
power to relax unstriped muscular tissue. For this reason, benzyl 
benzoate has been employed for all conditions due to spasm of such 
muscles, as in intestinal and uterine colic, in spastic constipation, 
pertussis, asthma, and even in the vascular spasm, local or general, 
as in angina pectoris. . 

The product is marketed in a 20 per cent, solution, each 10 drops 
equaling 2 drops of the drug. The dose is 15 to 60 minims (1.0-4.0) 
by the mouth, diluted with sweetened water, and it may be repeated 
every two or three hours if need be. The large doses seem essential 
in some cases— asthma and dysmenorrhea. The diagreeable taste 
of benzyl benzoate can be covered by adding to it from 1 to 4 minims 
of benzaldehyde and then diluting the dose with sweetened water or 
milk. 

BETANAPHTHOL. 

Betanaphthol, U. S., or Naphthol, B. P. A monhydric phenol 
occurring in coal-tar, but usually prepared from naphthalene. It 
should be kept in dark amber-colored, well-stoppered bottles. It 
occurs as a colorless or pale buff-colored, shining crystalline laminae 
or as a white or yellowish-white crystalline powder, having a faint 
phenol-like odor and a sharp and pungent but not persistent taste. 
It is permanent in the air. It is soluble in about 1000 parts of water, 
0.8 part of alcohol, 17 parts of chloroform, and 1.3 parts of ether at 
25° C. (77° F.) ; in about 80 parts of boiling water; soluble in glycerin 
and olive oil and easily dissolved by alkali hydroxide solutions. 

It is used externally in antiseptic dressings. Internally it is an 
excellent remedy for gastric fermentation and flatulence, as it acts as 
an active antiseptic. It is also useful in fetid diarrhea of the serous 



152 DRUGS 

type, and is valuable in uncinariasis. The dose is 2 to 5 grains (0.12- 
0.3) in capsule or cachet. The drug is useful as a local parasiticide. 

Betanaphthol-bismuth (Bismuthi Betanaphiholas, U. S.), or Orphol, 
is a neutral, odorless, and tasteless powder designed to combine the 
sedative effects of bismuth with the antiseptic properties of beta- 
naphthol. It is used in cases of serous and fermentative diarrhea in 
adults in the dose of 5 to 15 grains (0.3-1.0) and in children in the 
dose of 2 to 5 grains (0.12-0.3) given every few hours in capsule. 

Benzonaphthol is used as a substitute for betanaphthol in fermenta- 
tive dyspepsia. The dose is about 10 grains (0.6) three times a day, 
and it is best given in cachet. 

BISMUTH. 

Bismuth is employed in several forms or salts as follows, and is a 
valuable remedy. 

Bismuth and Ammonium Citrate. 

Bismuthi et Ammonii Citras (U. S.) is employed as a remedy for 
serous diarrhea. It is more irritating and astringent than the other 
salts of bismuth. The ammonium citrate contains not less than 46 
per cent, of the oxide of bismuth. The dose of this salt is 2 to 4 
grains (0.12-0.25). In the B. P. the following .preparation is official: 
Liquor Bismuthi et Ammonii Citratis, dose J to 1 fluidram (2.0-4.0). 

Bismuth Subgallate. 

The subgallate of bismuth (Bismuthi Subgallas, U. S.), is a fine 
bright yellow powder which is unaffected by prolonged exposure to 
light and air, is odorless, and is supposed to contain from 52 to 57 
per cent, of oxide of bismuth. Its external uses are identical with 
those of iodoform, and it probably acts in much the same manner as 
does the latter drug— namely, by so drying the wound that it becomes 
an unfavorable site for the growth of germs. As the subgallate is an 
astringent, it cannot be employed in the treatment of indolent ulcers, 
which need stimulation rather than an astringent influence, and it 
would seem probable on theoretical grounds that it is not to be 
compared to iodoform in the treatment of cases in which tubercular 
processes are active. 

There is no doubt that subgallate of bismuth is less poisonous than 
iodoform, but it must be capable of producing some untoward effects 
if used freely for any length of time, since poisoning follows the pro- 
longed employment of other bismuth preparations, as has been deter- 
mined by Balzer, Dalche, and Villejean, for the symptoms of which 
see the article on Bismuth Subnitrate. 

It may be tried in cases of skin disease in which there is much 



BISMUTH 153 

secretion, as in weeping eczemas and similar states, either in the 
form of a dusting-powder or in an ointment with vaseline or lanolin 
in the proportion of J to 1 dram to the ounce (2.0-4.0-30.0). 
Sometimes its efficiency can be much increased by the addition of a 
dram (4.0) of oxide of zinc to the prescription just given. 

Bismuth subgallate has been used with marked success in case of 
purulent otitis media as a dusting-powder, and in other states requiring 
similar drying and astringent effects. 

Internally, it has been highly recommended in cases of fermentative 
dyspepsia in the dose of 5 to 10 grains (0.3-0.6), but its real value in 
this condition is as yet undetermined. 

When first introduced bismuth subgallate bore the trade name 
"Dermatol." 

Bismuth Subnitrate and Bismuth Subcarbonate. 

Bismuth Subnitras (U. S. and B. P.), and Bismuth Subcarbonas 
(U. S.), or Bismuth Carbonas (B. P.), occur as white amorphous 
powders. Occasionally the subcarbonate may be a pale yellowish 
white. They may be used interchangeably, as they possess the same 
properties. The subnitrate should contain not less than 79 per cent, 
of bismuth oxide and the subcarbonate not less than 90 per cent. 
They are both insoluble in water except to a very slight degree. 

Physiological Action.— Bismuth in the form of subnitrate and 
subcarbonate is ordinarily devoid of effect upon the general system, 
and locally applied externally, or when given internally, exercises a 
mild astringent and protective influence upon mucous membranes. 

It may produce chronic poisoning after prolonged use on wounds, 
or when internally administered in excessive doses, for some time. 
Ordinary doses are innocuous. As much as 4 to 5 drachms a day 
may be given for a short time without harm. The changes which 
ensue when the drug is abused are pallor of the face, the formation 
of a black line on the gums, black sloughs in the mouth and gastro- 
intestinal tract, swelling of the tongue, salivation, desquamative 
nephritis, and albuminuria. Oliver states that a blue line on the 
gums resembling that seen in lead poisoning may develop. 

Two deaths in children have been reported under these conditions. 
One by Benecke and Hoffmann and one by Bohme. The latter has 
shown that the subnitrate is capable, under the influence of certain 
bacteria in the intestine, of giving off nitric acid and nitrites, and the 
symptoms of poisoning have been shown by Bohme to be due to the 
latter. The hemoglobin is changed into methemoglobin, as it is when 
the nitrites are used medicinally in large amounts. For this reason 
the subcarbonate is to be used in preference to the subnitrate for 
a:-ray examinations. 

The use of bismuth in single massive doses of as much as 2 to 4 
ounces (60.0-120.0) for the purpose of rendering the walls of the 



154 DRUGS 

stomach opaque to the a;-rays in cases of suspected gastro-intestinal 
disease has produced in some cases nausea, vomiting, prostration, 
cyanosis, and rapid pulse and quickened respiration. Formerly this 
drug was supposed to be capable of producing acute gastro-enteritis, 
when given in large doses, but this was due to contamination by 
arsenic. 

Therapeutics.— Bismuth subnitrate and subcarbonate are used as 
mild astringents in large doses to cover the surface of inflamed mucous 
membranes and so to allay irritation. It is useful in irritative vomiting 
for this reason, and in diarrhea of a similar type in which the stools 
are serous. If the passages are mucous, castor oil should precede 
bismuth in order to rid the alimentary canal of the mucous secretion 
already poured out. It is very useful when combined with phenol 
in serous diarrhea, given in capsules containing 10 grains (0.6) of 
bismuth subnitrate and 1 minim (0.05) of phenol. It may also be 
used as a slowly acting and feeble antacid. Bismuth is of service 
in dyspepsia when lactic- and butyric-acid fermentation is present 
with excessive belching, and may be employed in gastralgia and 
gastric ulcer and gastritis as a sedative and astringent. 

Milk of Bismuth (Magma Bismuthi, U. S.) is a suspension of hydrox- 
ide of bismuth now placed upon the market, the bismuth being 
minutely subdivided so that the tiny particles float in distilled water. 
It contains no glycerine, mucilage, sugar, or other substance, and 
each teaspoonful represents 5 grains of bismuth subnitrate. The 
dose varies from J drachm to f ounce, the latter dose being given to 
adults with gastric ulcer and the smaller dose to children with gastric 
irritation or acute gastric catarrh. It may also be employed as a lotion 
to superficial burns and in intertrigo. 

Bismuth subnitrate mixed with yellow petrolatum in the propor- 
tion of 30 per cent, has produced excellent results when injected into 
tubercular and other sinuses so as to thoroughly fill them. Enough 
force must be used to fill branch sinuses but not enough to tear the 
tissues. Before using, the paste is liquefied by heating it in a water- 
bath. Beck, the inventor of this treatment, states that if all parts 
are filled properly the creamy pus heretofore present will after 
twenty-four hours be found to be serous in character and sterile. 
Under these conditions reinjection is not necessary until the pus is 
no longer sterile, when they should be repeated weekly until sterile. 
Most of the injection usually exudes and the degree of its escape can 
be determined by the aid of the arrays. Not more than 1 ounce is 
usually necessary, and larger amounts may cause poisoning. If symp- 
toms of poisoning arise, warm olive oil should be injected, allowed to 
remain twelve to twenty-four hours and withdrawn by a catheter 
and suction syringe. The opening should not be closed but dressed 
with gauze. After the discharge becomes sterile the paste may be 
replaced by sterile vaseline. 

When the salts of bismuth are used for any length of time they 



BORAX AND BORIC ACID 155 

cause the odor of garlic in the breath, which is due to the presence 
of an exceedingly slight trace of tellurium in the bismuth. The 
stools are apt to become black under the influence of bismuth, and the 
tongue, if furred, may also be black about the center when bismuth 
is used. 

Where there is chapping of the hands or cheeks from exposure to 
cold or wet the following prescription is useful: 

1$ — Bismuthi subnitratis 5iij (12.0) 

Zinci oleatis 3iij (12.0) 

Lycopodii 3i.i (8.0).— M. 

S. — Apply to the parts t. i. d. 

Bismuth Subsalicylate. 

Subsalicylate of Bismuth (Bismuthi Subsalicylas, U. S., and Bis- 
muthi Salicylas, B. P.) is a white, soft powder, insoluble in water, 
alcohol, ether, and chloroform, but soluble in acids. It should con- 
tain not less than 62 per cent, nor more than 66 per cent, of bismuth 
oxide. It is largely used by some practitioners as an intestinal 
antiseptic in cases in which there is diarrhea due to fermentation or 
putrefaction. It may be given in powder, or, better still, in capsule, 
in the dose of 3 to 15 grains (0.2-1.0) several times a day. 

BORAX AND BORIC ACID. 

Borax Purification, B. P., or Sodii Boras, U. S., may be made by 
the action of boracic or boric acid upon soda, but the drug as it 
appears in commerce of America is derived entirely from natural 
deposits found on the shores of lakes in California and Nevada. 
The natural product has to be purified before it is marketable. 
Borax is soluble in 15 parts its weight of water at 77° F., and 0.6 
part in boiling water. Both borax and boric acid have been supposed 
to act as efficient germicides in strong solutions, but this has been 
proved incorrect. They are antiseptics, however, even in weak 
solutions. 

Upon the body borax has little effect in any dose which is given for 
medicinal effect. It is rapidly eliminated and renders the urine 
alkaline. It is too rapidly absorbed from the alimentary canal to 
permit it to act as an intestinal antiseptic. Boric acid exercises even 
less effect upon the system than borax. Borax may also be used as 
a gargle in diphtheria, in aphthous stomatitis, cancrum oris, and gan- 
grenous stomatitis. In the treatment of pruritus ani and vulva? and 
in bromidrosis and fetid sweating it is of great value, when used in 
solution as a wash. Strong solutions, locally applied, are useful in 
tinea tonsurans and tinea circinata. 

Borax has been used very largely in the treatment of epilepsy, with 
asserted success in some cases. Its employment is purely empirical. 
The dose used from 8 to 15 grains (0.5-1.0), gradually increased 



156 DRUGS 

until it produces disturbance in the alimentary canal. As the taste 
is very disagreeable to most persons, the drug should be used with 
liquorice, strong coffee, or syrup of bitter orange: 

]$ — Sodii boratis gss (16.0) 

Glycerini fgj (30.0) 

Fluidextracti glycyrrhizae fgij (60.0) 

Aquae destillatae q. s. ad f$vj (180.0).— M. 

S. — Dessertspoonful (8.0) in water after each meal. 

If larger doses than 15 to 30 grains (1.0-2.0) a day are continued 
after the convulsions are decreased in number, there are two diffi- 
culties: first, the good effect is rapidly lost; and, second, untoward 
symptoms, such as nausea and diarrhea, with emaciation and the 
formation of a scarlatinal, eczematous, or papular eruption, appear. 
A peculiarity of the last two eruptions is that they are distributed 
around the joints. 

A very useful wash for oral and nasal mucous membranes is 
"Dobell's solution," which is composed of— 

I^ — Sodii boratis, 

Sodii bicarbonatis ' . aa 5J (4.0) 

Phenolis gr. xxx (2.0) 

Glycerini f5j (30.0) 

Aquae purae Oij (960 cc). — M. 

Boric acid (Aaidum Boricum, U. S. and B. P.) is one of the most 
commonly used substances in eye-washes, either alone or with cocaine. 
When used with cocaine or other drugs it is employed to prevent the 
destruction of the alkaloid or glucoside, as the case may be, by the 
growth of mould. The following formula may be employed: 

1$ — Cocainae hydrochloridi gr. ivvelviij (0.25-0.5) 

Acidi borici gr. x vel xx (0.65-1.3) 

Aquae destillatae f^ij (60.0). — M. 

S. — To be used by dropping into the eye. 

The official ointment (JJnguentum Acidi Borici, U. S.) or the follow- 
ing makes a very useful application for the skin of the face and hands 
to prevent chapping: 

3— Acidi borici .....' 5J (4.0) 

Cerae albae 5J (4.0) 

Paraffini 3ij (8.0) 

Olei amygdalae expressi ... . . f5ij (8.0). — M. 

S. — To be thoroughly mixed and applied night and morning. 

If the form of a lotion boric, acid has been used with some success 
as a remedy for erysipelas, and it may be similarly employed in burns 
and scalds. 

Boric acid may be given internally in cystitis to render the urine 
acid, and is useful in the removal of freckles when applied as a wash 
to the skin. In persons having an idiosyncrasy to boric acid a bul- 
lous eruption of the skin may follow its use. 

Borated lint is made by dipping lint into a boiling saturated solu- 
tion of boric acid or borax. It is a simple, inexpensive antiseptic 



BROMIDES 157 

surgical dressing, and contains nearly one-half its weight of the drug. 
Mel Boracis, B. P., is not official in the U. S. P. It is used as a local 
application for sore mouth. 

BROMETONE. 

Brometone is produced by the action of caustic alkalies upon 
bromoform and acetone; it occurs in fine white prismatic crystals 
which possess a camphoraceous odor and taste. Its melting-point is 
about 167° C. It is soluble in most of the organic solvents, as alco- 
hol, ether, benzine, etc., slightly soluble in cold and more soluble in 
hot water. Its chemical name is tri-brom-tertiary-butyl-alcohol, and 
it contains 77 per cent, of bromine. 

The physiological action of brometone is nearly identical with that 
of the old bromides. Given in full doses it may, in susceptible 
persons, produce some dizziness, vertigo, loss of appetite, or mental 
heaviness, which are, however, only fleeting in their nature. Brome- 
tone may, therefore, be used as a substitute for the other bromides. 
It possesses the advantage of being powerful and therefore is effica- 
cious in small doses varying from 5 to 10 grains (0.3-0.6); best 
given in capsules. 

BROMIDES. 

Bromides of Potassium, Sodium, Lithium, Calcium, Gold, Nickel, 
Ammoniun, Strontium, and Hydrobromic Acid. 

Bromide of Potassium. 

Bromide of Potassium (Potassii Bromidum, U. S. and B. P.) is the 
most commonly used and an important member of the group above 
named, and will therefore be spoken of before the others. It is pre- 
pared by precipitating freshly-made bromide of iron with pure car- 
bonate of potassium, or by a process more readily carried out and 
recommended by the B. P. It occurs in colorless transparent crys- 
tals, which are stable in dry air, but absorb moisture in a damp 
atmosphere. It is very soluble in water, but less so in alcohol. This 
bromide has a salty taste, and is distinctly irritant to mucous mem- 
branes if locally applied in concentrated form. A certain portion of 
its depressant influence, particularly when it is given for long periods 
of time, depends upon the potassium as much as upon the bromine, 
and for this reason the sodium salt is preferable. 

Physiological Action.— Bromide of potassium has an action upon 
the animal economy which is clearly defined and closely followed 
by all the other bromide salts, so that what is said in this place 
concerning its effects may be taken as representing the whole class 
of bromides, except in the instances where slight differences exist, 
which will be pointed out under the various names of the respective 



158 



DRUGS 



salts. When taken internally in full doses it produces drowsiness, 
sleep, and a decrease in all the reflexes. (See Effects of Prolonged 
Use.) Because of its potash base it is more depressant than the other 
salts, and should be used with care in nephritis. 

Nervous System.— The bromide of potassium acts as a distinct 
depressant to the motor and to the intellectual portions of the cortex 
cerebri. It slows the development of thought and decreases the 
excitability and power of the motor cells of the brain (Albertoni). 
Upon the spinal cord it acts as a marked sedative, affecting chiefly 
the sensory tracts, and causing thereby loss of reflex action and a 
decrease in the ability to recognize pain. It also depresses, but to a 
less extent, the motor pathways in the cord. Motion is maintained 




Fig. 18. — A, the bromides depress the motor areas and B, intellectual areas in the 
brain; C, they depress the sensory tracts in the spinal cord; D, they depress reflex 
action by depressing the sensory cells in the cord a. 



after sensations to pain and reflexes are lost. The drug depresses the 
peripheral parts of the sensory nerves, and after very large doses the 
motor nerves and muscles are similarly involved. 

Circulation.— If the drug be injected in ordinary dose into the 
jugular vein, it causes at once a fall of arterial pressure and pulse- 
rate. These changes are due to a direct action of the bromine and 
the potassium upon the heart. When given to a man in therapeutic 
doses by the mouth, its circulatory effect is so slight as not to be 
worthy of consideration unless the dose is very large and repeated. 

Respiration.— In toxic dose bromide of potassium is a depress- 
ant to the respiratory center. In medicinal dose it does not affect 
the breathing, except when the amounts given are large and the drug 
persistently administered, when the breathing becomes slower. 



* • BROMIDES 159 

Digestion.— The bromides may disorder the stomach by irrita- 
ting its mucous membrane or by so decreasing reflex action that the 
proper secretion of gastric juice is retarded, with the result that 
digestion does not take place with sufficient rapidity. For similar 
reasons they may cause constipation. 

Temperature.— No effect upon this function is noted unless the 
dose be enormous; when such a dose is given the bodily heat is pro- 
gressively diminished, the fall of temperature being probably due to 
the circulatory and nervous depression produced, associated with the 
general failure in vital power. 

Elimination.— The drug escapes unchanged very slowly with all 
the secretions, and is found in the sweat, urine, tears, semen, milk, 
and feces. 

Tissue-waste is decreased when the animal economy is under the 
influence of one of the bromides. 

Therapeutics.— From what has been said, it is evident that bro- 
mide of potassium is a remedy to be devoted almost entirely to the 
treatment of disorders of the nervous system, and its uses are, 
therefore, as various as the manifestations of perversion of nervous 
action can be various. In a word, it may be said that bromide of 
potassium is to be used wherever over-excitement of nervous proto- 
plasm is present, but never where nervous symptoms are due to 
depression. 

In epilepsy, which, to the best of our knowledge, is due to explo- 
sive impulses arising in the cerebral cortex, it is one of the best drugs 
we have if given in sufficient dose; and in all forms of minor spasm, 
due to heightened reflex activity, it is of service. Care should be 
used in giving this drug in epilepsy that it is not used so long as 
to impair the mental state and that maniacal excitement does not 
supplant the attacks of epilepsy. (See Epilepsy, Part IV.) In 
cases of spasmodic contractions, in the treatment of hysterical females, 
in nervous startings and alarm at sudden noises in adults and children, 
and in the nervous symptoms accompanying pregnancy and the meno- 
pause the bromides will be found of great value. The following 
prescription was recommended very highly by Goodell, and will be 
found of service in the latter states: 

R — Ammonii bromidi 5ij (8.0) 

Potassii bromidi 3iv (16.0) 

Spiritus ammonii aromatiei f3vj (24.0) 

Aquae camphorse q. s. ad fgvj (180.0). — M. 

S. — A dessertspoonful (8.0) to a tablespoonful (16.0) every four hours. 

In headaches due to uterine trouble the pain is often felt at the top 
of the skull or at the back of the neck near the occiput. The cause 
of this trouble will sometimes be found to be in the cervix uteri, and 
relief under these circumstances can only be obtained when the uterus 
is treated and the bromides administered. 

In convidsions in children and adults, combined with chloral, bro- 



160 DRUGS 

mides are most efficient, and are sometimes of service in incontinence 
of urine due to vesical spasm. In seminal emissions due to a morbid 
excitability of the centers in the spinal cord, bromide of potassium is 
one of the best remedies we have, and in satyriasis and nymphomania 
it is of great service. 

In cases where undue irritability of the pharynx and larynx prevents 
examination of these parts, one or two full doses will render an ex- 
amination easy of performance by decreasing the local reflex activity. 
This is a useful point to be remembered in relation to the treatment 
of pharyngeal and laryngeal disease. 

In cases of acute laryngitis full doses of the bromides (60 to 120 
grains [4.0-8.0] a day) are very useful to allay the pain and hoarseness. 

The bromides are found to be of service in the laryngeal crises of 
locomotor ataxia, the explanation of this fact being as follows: The 
adductor center of the larynx is situated in the brain, and the abduc- 
tor center in the spinal cord. The first closes the larynx, the second 
opens it, and in health they maintain a patulous tube by their opposi- 
tion. In disease the spinal center (the abductor or opener) fails, 
and the adductor in the brain, being unopposed, produces closure of 
the tube with disastrous results. The bromide, by quieting reflex 
action, as well as depressing the adductor center in the cerebral cortex, 
prevents this accident. 

In whooping-cough with much mucous exudation the drug is rarely 
of benefit, and had better not be used. In laryngismus stridulus or 
any form of spasm depending upon local irritation the local trouble 
must, of course, be removed if possible and the bromides given. In 
teething the drug may be used to decrease reflex irritation and pre- 
vent convulsions, and it will decrease the night-screaming of children 
—which is often due to bad dreams— to a very extraordinary degree, 
even if the dose be quite small. As a soporific for the insane and in 
the insomnia of the overworked and that of nervous women the 
bromide of potassium is of great service, but ought to be used as a 
temporary measure only. (See Insomnia) . It may also be employed 
with good results in chronic alcoholism and morphinomania, given in 
doses of 40 to 60 grains (2.6-4.0). In migraine and neuralgia due 
to eye-strain or nerve-strain, combined with caffeine, the bromides are 
almost specifics. The caffeine seems to stimulate the depressed nerve 
up to the normal level, and the bromide to deaden the perception of 
the pain. The following is a most valuable remedy in migraine, and 
also in sick headache. It ought not to be used in bilious headache, 
which will often be made worse by it: 

1$ — Antipyrinse gr. xxv (1.6) 

Caffeinse gr. x (0.6) 

Potassii bromidi gr. xxv (1.6). — M. 

Fiant chartulse, No. v. 

S. — One powder in water as needed. 

In the treatment of dysmenorrhea and menorrhagia, particularly 
in young subjects, the bromides are also of service. (See Goodell's 



BROMIDES 161 

prescription, page 159). When the flow is too profuse, the drug 
should be begun a week before the expected epoch, and given in the 
dose of 5 to 10 grains (0.3-0.6) night and morning. In cases where 
the epochs follow one another too closely the drug should be used 
continuously. After an apparent cure ensues the bromide should 
be continued for a few periods to avoid a relapse. For seasickness 
the bromides are the best prophylactics we possess, and should be 
used in the dose of 5 to 10 grains (0.3-0.6) three times a day for 
several days before the patient sails, in order to quiet the vomiting 
center. After seasickness begins they should not be given in ordinary 
solution, but in an effervescing draught made as follows: 

1$ — Acidi citrici 5ij (8.0) 

Aquae destillatse fgiv (120.0) —M. 

Fiat solutio. 

1$ — Potassii bromidi 3J (4.0) 

Potassii bicarbonatis 5J (4.0) 

Aquae destillatse fgiv (120.0). — M. 

Fiant solutio. 
S. — A tablespoonful (16.0) of each of these solutions should be added to one another 
and taken during effervescence. 

This prescription will also be found of value in the persistent vomit- 
ing of pregnancy and in that following prolonged etherization or 
other states. If the vomiting is excessive, the dose ought to be 
reduced to 2 teaspoonfuls (8.0) of each solution, and be given every 
half -hour until half of each mixture is taken or the patient is relieved. 
In cases where this cannot be retained, a rectal injection of the 
following will be found of value: 

1$ — Sodii bromidi gr. xxx vel 5J (2.0-4.0) 

Tincturae opii deodorati TUxxx (2.0) 

Mucilaginis amyli f5vj (180.0). — M. 

S. — To be injected gently into the empty rectum and retained as long as possible. 

This method is one of the most reliable plans that can be followed. 

Bromide of potassium may be used to prevent the development of 
symptoms of cinchonism, which often ensue after the use of quinine 
and salicylic acid, and it is said to prevent the nausea and depression 
so apt to follow the use of opium. 

Administration.— The dose of bromide of potassium is from 5 to 
120 grains (0.3-8.0) a day. It should be given at long intervals, as 
it is slowly absorbed and very slowly eliminated. After the patient 
is fully under its influence its effects can be maintained by smaller 
doses. The best way to order it is in a watery solution with a little 
syrup. 

Use of Bromides in Poisoning.— Bromides are useful in nearly all 
convulsive attacks consequent upon the ingestion of poisons, and they 
may be used to allay any nervous symptoms arising from this cause 
which are of an exciting nature. 

Poisoning.— Acute poisoning by the bromides is rare, but if \ to 
1 ounce is taken they produce a sense of warmth in the epigastrium, 
11 



162 DRUGS 

general feebleness, frontal headache, stupor, aphasia, and amnesia. 
The pulse-rate decreases 15 to 20 beats a minute; the pulse is irregular 
and compressible. Recovery takes place, as a rule, unless pulmonary 
edema set in. Occasionally the patient may become maniacal. 

Effects of Prolonged Use, or Bromism.— After the drug has been 
used for some time in large doses acne appears about the face and 
extends over the entire body; the breath becomes fetid, the patient 
is dull, expressionless, and heavy, and remains buried in sleep during 
nearly every hour of the day. During this time he can be aroused, 
but at once sinks to sleep again. The gait becomes weak and feeble, 
the movements slow and prolonged. Taste is lost and hearing is 
benumbed, while the intellectual faculties of the brain are almost in 
abeyance. Loss of sexual power is an early symptom. In other 
cases evidences of mental aberration develop, the patient becoming 
irritable, morose, and even homicidal. Sometimes, however, we find 
melancholia and hallucinations, and rarely exalted ideas, 1 with symp- 
toms resembling general paresis. In still others a dangerous suffoca- 
tive bronchitis develops, the patient may become profoundly cachec- 
tic, or the condition may resemble typhoid fever. The acne may be 
prevented to some extent by the use of arsenic, and when the bromides 
are given to women this drug may be given simultaneously to pre- 
vent the eruption. As Fowler's solution is compatible with the 
bromide in solution, it is the best form of arsenic to employ. As 
the acne is due to a torpid state of the skin-glands, it is also well 
in these cases to order the patient to wash with warm water and 
Castile soap every night, and afterward to dry the face by a vigorous 
rubbing with a rough towel. Fere has asserted that the maintenance 
of intestinal antisepsis by the use of naphthol or salol will prevent the 
development of acne and digestive disorder when the bromides are 
given. 

Contraindications.— The bromides are contraindicated wherever 
there is general asthenia and feebleness of the nervous system, as, for 
example, in post-typhoidal and post-puerperal insanity. In senile 
softening of the brain they are also harmful. When the mucous 
membrane of the gastro-intestinal tract is irritated, they do harm. 
When the patient is subject to acne, they should be used with caution 
or avoided. 

Bromide of Ammonium. 

(See Ammonium Bromide.) 

Bromide of Calcium. 

Calcium Bromide (Calcii Bromidum, U. S.) was introduced into 
medicine as a nervous sedative and hypnotic, and was thought at one 
time to be an efficient substitute for the bromide of potassium. Its 

1 See Collective Investigation by author in the Therapeutic Gazette of June 15, 
1897; also article on Epilepsy, Part IV. 



BROMINE 163 

action on the nervous system is virtually identical with that of the 
potassium salt, and it has been found to be far less irritant and depres- 
sant than the latter. For some unknown reason it has never won the 
confidence of the profession, but it may be given with very good 
results in the dose of from 30 to 90 grains (2.0-6.0) a day, or even more 
in cases which are not readily effected by bromides. It may be 
employed in hysteria and epilepsy and in all the conditions in which 
the other bromide salts are indicated. It is sometimes of value 
combined with the potassium salt, since under such circumstances 
better results are gained than if a single salt is employed. 

Bromide of Ethyl. 

See Ethyl Bromide. 

Bromide of Lithium. 

Bromide of Lithium (Lithii Bromidum, U. S.) is much weaker than 
the other salts, and must be given in larger dose. S. Weir Mitchell 
stated that it is of value in epilepsy when the potassium salt fails. 
The dose is 30 to 90 grains (2.0-6.0) a day. 

Bromide of Sodium. 

Bromide of Sodium (Sodii Bromidum, U. S. and B. P.) is to be 
used in every instance where bromide of potassium can be employed. 
Its dose is the same, although it is asserted to be a little weaker 
physiologically, grain for grain, than the potassium salt. It is far 
less apt to disorder the stomach, and is not so generally depressing 
as is the bromide of potassium. 

Bromide of Strontium. 

See Strontium. 

Hydrobromic Acid. 

Hydrobromic Acid is an extremely irritant preparation, but is 
thought to be less apt to cause acne and other untoward effects than 
the other bromides. It is only to be used in the form of the official 
dilute acid (Acidum Hydrobromicum Dilutum, IT. S. and B. P.) and 
to be given in the dose of from 1 dram to § ounce (4.0-15.0), 15 
to 60 minims (1.0-4.0) B. P., well diluted with sweetened water. It 
is highly recommended by de Schweinitz and others for headaches 
due to eye-strain in nervous women. 

BROMINE. 

Bromum is a dark red liquid of an excessively pungent odor, 
like that of chlorine, possessing extraordinary power as a caustic 



164 DRUGS 

when applied to the tissues of the body. It is the most severe caustic 
we possess, and penetrates very deeply. It may be applied in hospital 
gangrene and other large sloughs by means of a glass rod. Bromine 
should be kept in glass-stoppered bottles in a cool place. 

BROMOFORM. 

Bromoformum (U. S.) or Tribromomethane, is a clear, colorless 
liquid having a peculiar odor and sweet taste, consisting of 96 per 
cent, of absolute bromoform and 4 per cent, of absolute alcohol. It 
is readily soluble in alcohol, but slightly so in water. Bromoform 
which is to be used medicinally should be protected from sunlight 
and air, and must be free from color and from acid. 
jr Therapeutics.— Although bromoform has been found capable of 
producing anesthesia when given by inhalation, its employment is 
confined to the treatment of whooping-cough, in the dose of 1 to 5 
minims (0.1-0.3) three times a day for the relief of the spasmodic 
cough. It may be put in a teaspoonful of syrup and mixed at the 
moment of taking. Bedford has suggested the following formula for 
its internal use: 

1$ — Bromoformi ITlxvj (1.0) 

Alcoholis f5ij (8.0) 

Glycerini f5xij (45.0) 

Tincturae cardamomi composite . . q. s. ad f $ij (60.0). — M. 

S. — Teaspoonful (4.0) t. i. d. in water. 

This prescription should be compounded by adding the ingredients 
in the order named. 

Bromoform tends to depress the vasomotor system, but does not 
seem to depress the heart itself. While it seems to possess therapeutic 
value, the large number of cases reported in which it has caused 
alarming symptoms has prevented the author from employing it. 

BRYONIA OR BRYONY. 

Bryonia is a remedy very largely used by irregular physicians, and is 
probably too much ignored by reputable physicians, for it possesses 
very great power, and sometimes relieves conditions which are obsti- 
nately persistent under other treatment. It is the root of Bryonia 
alba or Bryonia dioica. The preparation commonly employed is the 
tincture {Tinctura Bryonia). The dose of the powdered root as a 
drastic purge is 10 to 40 grains (0.6-2.6). 

Physiological Action.— In overdoses bryonia acts as a hydragogue 
cathartic and gastro-intestinal irritant. On serous membranes it 
exercises an irritant influence, and may produce symptoms of menin- 
gitis when given in poisonous doses. In moderate doses bryonia 
causes some flushing of the face and neck and headache in susceptible 
persons. The drug needs studying from a pharmacological point of 
view. 



BUCHU 165 

Therapeutics.— Although one of the oldest of remedies, bryonia has 
been given a new impetus by the homoeopaths, who employ it in a 
number of affections. In the treatment of dyspepsia depending upon 
gastric and intestinal atony bryonia often gives relief. Its influence is 
exerted through the irritant effects it produces, for by this means it 
stimulates or spurs the atonic digestive glands to increased activity. 
For this reason it has been found particularly useful in children who 
suffer from constipation resulting from insufficient secretion on the 
part of the intestinal glands. When the passages are dry and friable 
and resemble in character those of a dog, bryonia is of great value. 
The dose for a child is about 10 to 20 minims (0.6-1 .3) . The drug has 
been praised as a remedy in the treatment of rheumatism and in 
pleurisy, but little is recorded as to its real value in these diseases. In 
pleurisy with effusion drastic doses have been used, but the saline 
purgatives are safer and more efficacious remedies. 

Administration,— The dose of the tincture of bryonia {Tincture 
Bryonia) is from 1 to 2 fluidrams (4.0-8.0) as a laxative; but the 
so-called mother-tincture of the homoeopaths is perhaps the best pre- 
paration for ordinary use. The proper amount to be used in the 
treatment of a case of dyspepsia is from 5 to 40 minims (0.3-2.6), 
unless the mucous membranes are very torpid, when this quantity 
may be increased. 

BUCHU. 

Buchu (U. S.) is the dried leaves of Barosma betulina, a plant of 
Africa. It contains a volatile oil, which is probably the active 
principle, and a bitter extractive. It is official, under the name of 
Buchu Folia, in the B. P. 

Therapeutics.— Buchu is used when it is desired to affect the mucous 
membranes of the genito-urinary tract which are chronically diseased, 
and particularly when these parts are below their normal tone. It 
does not increase the urinary flow to any great extent, but acts on the 
mucous membrane of the genito-urinary passages as a stimulant. It 
is employed in pyelitis, cystitis and vesical irritation of a chronic type. 
The following prescription is useful : 

3 — Potassii citratis 5iv (16.0) 

Spiritus chloroformi f3iij (12.0) 

Tincturse digitalis Tfl.xxx (2.0) 

Infusi buchu q. s. ad fgviij (240.0). — M. 

S. — Two tablespoonfuls (30.0) three times a day. Shake the bottle before using. 

If the urine is continually highly acid, muddy, laden with salts, 
and productive of incontinence by reason of the vesical irritation 
which it produces, buchu in the form of the fluidextract, in the dose 
of a teaspoonful (4.0) three times a day, combined with an equal 
amount of sweet spirit of nitre and 20 grains (1.3) of acetate of potas- 
sium will be of great service. For a child the dose of the fluidextract 
should be about 10 to 30 minims (0.9-2.0). If the vesical irritation 
is acute, buchu is contraindicated. 



166 DRUGS 

Administration.— The fluidextract {Fluidextr actum Buchu, U. S.) is 
the only official preparation, and it should be always well diluted 
before it is given, in the dose, to an adult, of 1 dram (4.0) three 
times a day. The infusion is not official, but is made by adding 1 
ounce (30.0) of the leaves to a pint (480 c c) of water. The dose of 
this is J ounce (16.0) to 1 ounce (30.0). The official B. P. prepara- 
tions are the infusion (Infusum Buchu), dose 1 to 2 fluidounces 
(30.0-60.0) , and the tincture ( Tinctura Buchu) , dose J to 1 fluidram 
(2.0-4.0). 

CACTUS GRANDIFLORUS. 

This is a plant of Mexico and the West Indies. There are other 
species of Cactus possessing medicinal power, but Cactus grandiflorus 
is said to be the most active so far as a medicinal effect upon the 
heart is concerned. 

Cactus grandiflorus is best given in the form of the tincture or the 
fluidextract made from the green plant. 

Physiological Action.— The drug has been studied by Myers and 
Boinet and Teissier, who assert that it causes a distinct increase of 
arterial pressure, but does not slow the pulse, sometimes increasing its 
rapidity. According to Sayre and Houghton, however, it is not pos- 
sessed of much power, and their conclusions have been proved correct 
by others. 

Therapeutics.— Cactus grandiflorus has been used as a remedy for 
cardiac palpitation and weakness, but it is a very feeble remedy. 

Administration.— The dose of the tincture of cactus is 2 to 8 minims 
(0.1-0.5) and of the fluidextract 2 to 4 minims (0.1-0.25). 

CAFFEINE. 1 

Caffeine (Caffeina, U. S. and B. P.) is an alkaliod derived from Thea 
Camellia and the berries of Caffea Arabia, which also contain, upon 
roasting, an empyreumatic oil, caffeol or caffeone. Caffeine occurs as 
white, flexible, silky, glistening needles, usually matted together 
in fleecy masses, permanent in the air; odorless and having a bitter 
taste. If crystallized from water, it contains one molecule of water 
of crystallization, but if it is crystallized from alcohol, chloroform, 
or ether it contains none. It is soluble in 46 parts of water, 66 
parts of alcohol, 530 parts of ether, and 5.5 parts of chloroform at 25° 
C. (77° F.); soluble in 5.5 parts of water at 80° C. (176° F.) and in 22 
parts of alcohol at 60° C. (140° F.) . Its solubility in water is increased 
by the presence of certain salts— e. g., potassium bromide, sodium 
benzoate, sodium salicylate, and others. • 

1 Theine derived from tea, caffeine, the active principle of coffee, and the alkaloid of 
guarana from South America, a,re chemically identical. All of the caffeine of com- 
merce is really theine, although it is claimed that pure theine has a' very different 
physiological action. 



CAFFEINE 



167 



Caffeine is usually employed in medicine as caffeine and the citrated 
caffeine (Caffeina Citrata, U. S.; Caffeince Citras, B. P.). Citrated 
caffeine is not regarded by chemists as a chemical compound, but as 
a mixture of citric acid and caffeine; therefore "citrate of caffeine" 
is an incorrect term. It occurs as a white powder, odorless, having 
a slightly bitter, acid taste and an acid reaction. One part of citrated 
caffeine forms a clear, syrupy solution with about 4 parts of hot water. 
If more water is added, it is partly precipitated, but when 25 parts 
are added it is redissolved. In the U. S. P. another official prepara- 
tion of caffeine, the Caffeina Citrata 
Effervescens {Caffeina Citras Effer- 
vescens, B. P.), has been introduced 
as an agreeable preparation for 
use in cases of headache, particu- 
larly if combined with one of the 
bromides and antipyrine. The 
dose is from J to 2 drams (2.0- 
8.0) in water. 

The empyreumatic oil, of which 
there is about one-half to one tea- 
spoonful in each well-made break- 
fast cup of coffee, has no physio- 
logical effects. It is perhaps the 
cause of the " biliousness" some- 
times produced by the habitual 
use of coffee, due to the faulty 
digestion of this oil, which is also 
prone to disorder the digestion if 
taken alone. 

Physiological Action.— Nervous 
System.— On the nervous system 
caffeine acts as a rapidly-acting 
stimulant, exerting its chief influ- 
ence on the brain and spinal cord. 
By its cerebral effect it causes in- 
creased rapidity of thought, and 
by its influence on the spinal cord 
it increases reflex activity, and 
for this reason is said to make people "nervous." It is important 
to remember that it has no effect on brain protoplasm except to 
increase its functional activity. Caffeine does not produce cerebral 
exhaustion unless it is taken in such a manner and such large doses 
as to interfere with sleep, rest, and the taking of food in ordinary 
quantities. Hollingworth has shown that an individual is enabled to 
do more mental work in a given space of time with caffeine than he 
is capable of doing without it, and that this increased work is not 
followed by depression or exhaustion. In other words, it acts as a 




Fig. 19. — Caffeine dilates bloodvessels 
of the Malpighian tuft and stimulates 
the secreting epithelium lining the urinif- 
erous tubules. 



168 DRUGS 

lubricant does in machinery, increasing ability without causing 
exhaustion. H. C. Wood, Jr., has shown that it acts on the muscles 
in a similar manner, and Farr's studies on urinary output fail to show 
that it causes an evidence of increased muscle break-down. 

Hektoen and Le Count have shown that the continual use of caffeine 
in doses such as are commonly found in tea and coffee produce no 
lesions in any tissues of the body. 

Circulation.— Caffeine has been supposed to increase the pulse- 
rate and blood-pressure by stimulating the heart-muscle, but from 
recent studies in the United States and abroad it would seem prob- 
able that these changes are indirectly produced and due chiefly 
to its stimulating action on the nervous system. Clinically, it 
certainly seems to raise the blood-pressure in many instances of 
low pressure. 

Kidneys, Tissue-waste, and Elimination— Caffeine increases 
diuresis by causing dilatation of the renal vessels, particularly in the 
glomerules, and by preventing the absorbent action of the tubules. 
It also exerts a direct stimulating influence on the secretory epithelium 
of the kidney, and therefore increases the amount of solids as well as 
of the liquids in the urine. Upon tissue-waste the drug acts as a 
depressant, and is therefore a conservator of the tissues. It is 
oxidized and destroyed in the body. 

Respiration.— Caffeine acts as a valuable stimulant to the respira- 
tory center. 

Therapeutics.— Caffeine is a valuable cardiac stimulant and tonic as 
well as a renal stimulant. It acts equally well in cardiac and renal 
dropsies for this reason, and is an invaluable remedy in such cases. So 
useful is caffeine in cases of cardiac disease that it has largely sup- 
planted digitalis in the hands of some practitioners, but its action is so 
different from that of foxglove that it cannot be considered in the same 
class of stimulants. In acute renal inflammation it is contraindicated, 
because all stimulants are contraindicated when the part they influ- 
ence is inflamed. In opium poisoning, owing to its stimulant effect 
on the respiratory center, caffeine is very valuable. It may be given 
by the mouth or rectum in the form of strong black coffee, which 
will also aid in keeping the patient awake and add heat to the body, 
which is often very cold, or by the hypodermic needle. A cup of 
strong black coffee is often useful in relieving a paroxysm of asthma. 
In headache due to nerve-strain caffeine combined with antipyrine 
or acetphenetidin, and one of the bromides, is often of the greatest 
service. (See Bromide of Potassium and Neuralgia.) 

Roasted coffee is sometimes used to mask the taste of disagreeable 
medicine. After it is roasted and ground it may be employed as an 
antiseptic and deodorant dressing for wounds when the common anti- 
septics are not obtainable. 

Administration.— The ordinary dose of caffeine is 2 to 4 grains (0.12- 
0.25). 



CALCIUM 169 

Caffeina, U. S. and B. P., cannot be used hypodermically, owing to 
its decomposition in the presence of water. The following solution 
may, however, be used hypodermically: Salicylate of sodium, 30 
parts; caffeine, 40 parts; and distilled water, 60 parts; or, in other 
instances, the following preparation, recommended by Huchard, may 
be employed: Benzoate of sodium, 45. grains; caffeine, 30 grains; 
distilled water, 75 grains. This mixture is to be heated, and 10 
minims (0.6) given at a dose. An excellent formula which can be 
used hypodermically combining the stimulant properties of caffeine 
and camphor is as follows: 

1$ — Caffeinae, 

Sodii salicylates aa gr. iv 

Aquae destillatse TTlxv 

Misce et adde 

Spiritus camphorae (10 per cent.) ITlxv 

It is asserted that this formula when made remains clear for a long time. 

The U. S. P. has made Caffeines Sodio-benzoas official for this 
purpose. 

Untoward Effects.— Caffeine often produces so much insomnia when 
given in full doses in cases of cardiac disease that its use has to be 
discontinued. If its use is persisted in, it may produce a condition 
of delirium closely resembling that of alcoholism. The writer has 
also seen a marked rise of temperature in a patient follow its use in 
the doses of 2 grains (0.12) three times a day, but this is unusual. 
In certain persons the habitual use of coffee in excess in the presence 
of overwork and lack of sufficient rest and food may result in insomnia, 
tremors, palpitation, tinnitus aurium, gastralgia, and emaciation. 

CAJUPUT OIL. 

Oil of Cajuput (Oleum Cajuputi, U. S. and B. P.) is a volatile oil 
distilled from Melaleuca Leucodendron, a tree of the Molucca Islands. 
It is a stimulant, and in large amounts an irritant, to mucous mem- 
branes, but acts as an efficient carminative and parasiticide in mod- 
erate amounts. As a remedy for tinea tonsurans and pediculi it 
should be applied pure to the part affected and used with caution, for 
cajuput oil is capable of irritating the skin. In diarrhea of a serous 
type it is of value in the dose of 10 to 20 minims (0.6-1.3), J to 3 
minims (0.03-0.18), B. P. (See Diarrhea.) Spiritus Cajuputi is 
official in the B. P.; dose 5 to 20 minims (0.3-1.2). 



CALCIUM. 

Calcium is official in a number of forms, and is to be distinctly 
separated in the mind of the student from calx or lime, which is an 
oxide of calcium. It is never employed as calcium, but as one of its 
salts. These are as follows: bromide of calcium (Calcii Bromidum, 



170 DRUGS 

U. S.); precipitated carbonate of calcium (Calcii Carbonas Precipi- 
tatus, U. S. and B. P.); chloride of calcium (Calcii Chloridum, U. S. 
and B. P.) hypophosphite of calcium (Calcii Hypophosphis, U. S. and 
B. P.); and as precipitated phosphate of calcium (Calcii Phosphas 
Precipitatus; Calcii Phosphas, B. P.; Calcii Glycerophosphas, U. S. 
and Calcii Lactas, U. S.). Calcium sulphate is official in the B. P. 
All salts of calcium are incompatible with acids. 

Carbonate of Calcium. 

The precipitated carbonate (Calcii Carbonas Precipitatus, U. S. and 
B. P.) of calcium is used an the treatment of serous diarrhea as an 
antacid and as a local protective in cases of chapped skin or intertrigo, 
particularly in young children. When given internally the dose is 
from 10 to 30 grains (0.6-2.0). 

Precipitated carbonate of calcium is the slowest acting antacid which 
we possess, and for this reason the remedy is to be employed in acidity 
of the intestines, as it passes through the stomach to a very great 
extent unchanged. (For the varieties of diarrhea in which it is to be 
used see article on Diarrhea.) As an external application it is used in 
sweating of the feet and hands, and sometimes as a dry dressing to 
ulcers. It may also be used over burns. 

Chalk.— Chalk is a native calcium carbonate, chiefly obtained 
from shells. 

Prepared chalk (Cretan Prceparata, U. S. and B. P.) is given in the 
dose of 20 to 60 grains (1.3-4.0). By far the best method for its 
administration is in the employment of chalk mixture (Mistura Cretce, 
U. S. and B. P.), which contains about 30 grains of the chalk to each 
ounce (2.0-30.0) of liquid. The dose of this mixture is from 1 dram 
(4.0) for a young child to an ounce (30.0) for an adult. In the treat- 
ment of cases of serous diarrhea chalk mixture is best given in com- 
bination with tincture of kino or the compound tincture of gambir and 
paregoric, in some such form as follows : 

3— Tincturse kino 5J (30.0) 

Tincturse gambir compositi f3ij (8.0) 

Misturse cretae q. s. ad fgvj (180.0).— M. 

S. — A dessertspoonful (8.0) every three hours until diarrhea ceases. 

It is to be remembered that the chalk mixture acts very slightly as 
an astringent, and chiefly as an antacid and mechanical agent in the 
alimentary canal. 

Chalk made into a paste may be used as a substitute for bismuth 
paste in the treatment of sinuses. (See Bismuth.) 

Other preparations are compound chalk powder (Pubis Cretan Com- 
positus, U. S.), composed of prepared chalk, acacia, and sugar, and 
given in the dose of 10 to 60 grains (0.6-4.0), and troches of chalk 
(Trochisci Cretce). Preparations official in the B. P., but not in 



CALCIUM 171 

the U. S. P., are aromatic powder of chalk Pubis Cretce Aromaticus,) 
dose 10 to 60 grains (0.6-4.0), and Pubis Cretoe Aromaticus cum Opio, 
dose 10 to 40 grains (0.6-2.4). 

Calcium Chloride and Lactate. 

Calcium chloride (Calcii Choloridum, IT. S. and B. P.) when taken 
internally in large amount acts as an intense gastro-intestinal irritant, 
and may produce death by this means. It is to be distinctly separated 
from the chlorinate, or chloride, of lime, with which it is sometimes 
confused, for the latter is hydrate of lime or slaked lime, containing 
30 per cent, of chlorine, while chloride of calcium is a hard, vitreous, 
friable substance, giving off no odor of chlorine and utterly different 
in its use, action, and appearance. 

In cases where boils mature slowly a poultice made by adding a 
solution of chloride of calcium to the mass may be used to hasten 
suppuration. 

Another use of calcium chloride, which is worthy of trial, is its 
employment in the treatment of itching. It should be given in the 
dose of 20 grains (1.3) three times a day to an adult and may be pre- 
scribed as follows: 

1^— Calcii chloridi 3ij (8.0) 

Tincturse aurantii f 3vj (24.0) 

Aquae chloroformi q. s. ad f Svj (180.0). — M. 

S. — One or two tablespoonfuls (16.0-30.0) three times a day. 

Smaller doses may be needed if the stomach is irritable. These 
doses usually produce some thirst. They should be taken about one 
hour after a meal. 

Small doses of calcium chloride have also been used to increase the 
coagulability of the blood in "bleeders" and to prevent attacks of urti- 
caria by an influence on the blood plasma, particularly in those cases 
in which the state of the blood has been altered by the ingestion of acid 
fruits. When used the dose should be 20 grains (1.3) three times a 
day. Unfortunately, as already stated, it is apt to disorder the stom- 
ach. A better preparation for this purpose is calcium lactate (Calcii 
Lactas, U. S. and B. P.). Calcium chloride, or lactate, may also 
be used to relieve albuminuria, which is not dependent upon organic 
disease of the kidneys but to conditions in the blood which permit 
an escape of albumin through the renal bloodvessels. Indeed, its 
ability to control so-called physiological albuminuria may permit us 
to use it to differentiate albuminuria due to organic renal disease, 
which it cannot control, from that type called "functional" The 
effect of the drug upon bleeding and albuminuria is usually mani- 
fested within an hour or two and persists for several days. An 
important point to be remembered is that the too prolonged admin- 
istration of calcium decreases rather than increases the coagulability 
of the blood. The use of the drug should therefore be stopped for 



172 DRUGS 



several days after it has been taken for 6 or 8 doses. It is also 
important to remember that some cases of hemophilia or purpura 
seem unable to absorb the calcium salts from the alimentary canal. 
Such cases should be treated by the use of calcium lactate hypo- 
dermically, the solution of which should not be stronger than 1 to 
20 of water. Calcium chloride is too irritating for hypodermic use. 
Addis has seemed to prove that it is not possible to shorten coagu- 
lation time by the use of calcium salts. The question as to their 
employment for this purpose is therefore sub judice, the more so as 
it is becoming more and more evident that^as the blood contains a 
very small amount of calcium and can always get all it needs from 
the bones. Ross has reported the successful use of calcium chloride 
and lactate, when given by the mouth, in cases of persistent dull 
headache associated with heaviness, listlessness, a lymphatic tempera- 
ment, and decreased coagulability of the blood. 

Very large doses of the calcium salts have recently been recom- 
mended for the relief of persons suffering from tetany due to disease 
or injury of the parathyroid glands and for the tetany of lactation and 
pregnancy by W. G. MacCallum and Voegtlin. 

Calcium Hypophosphite and Precipitated Calcium Phosphate. 

The hypophosphite of calcium and the precipitated phosphate of 
calcium are used for the treatment of scrofulous or strumous states 
and allied conditions, such as rachitis, generally in the form of the 
Syrupus Hypophosphitum, U. S., and the Syrupus Calcii Lacto- 
phosphatis, U. S. and B. P. 

The large amount of phosphate of calcium normally present in the 
bones and tissues renders it a useful drug when the body is starved 
of its proper proportion of salts, and its use has been found, in animals, 
to cause a great increase in bony growth, not only in the earthy, but 
also in the animal, constituents of the osseous tissues. The hypo- 
phosphite has a similar effect. 

In rickets and in fractures where the bone is slow in uniting, and in 
some cases of phthisis and scrofula, the lactophosphates and hypo- 
phosphites have been thought to be of service. 

It is worthy of note that these salts are of little value in tubercu- 
losis after it is well developed. They do good, if at all, in the so-called 
pretubercular or beginning stages of the disease; and the good effects 
of the so-called syrups of the hypophosphites depend more upon the 
other ingredients present in them than upon the calcium salts they 
contain. In dental caries particularly that occurring in nursing 
women they are useful. 

The lactophosphates are better than the hypophosphites, as the 
latter are probably changed into phosphates in the stomach as soon 
as they enter that viscus. The dose of either the lactophosphates or 



CALX 173 

the hypophosphites is 10 to 30 grains (0.6-2.0) three times a day, or 
of the syrups just named a teaspoonful to a tablespoonful (4.0-16.0). 
The difference between these salts and phosphorus, both in thera- 
peutical effect and in physiological action, is to be clearly borne in 
mind. The lactophosphates and hypophosphites are simply con- 
venient modes of administering calcium, potassium, or other sub- 
stances, while phosphorus acts as a stimulant to bone-growth, and 
not by its deposition in the bone. Phosphoric acid does not act any 
more like phosphorus than does sulphuric acid act like sulphur. 

Sulphate of calcium is not to be confounded with calx sulphurata, 
often wrongly called sulphide of calcium. (See Boils and Calx.) 

CALUMBA. 

Calumba (U. S.), Calumbos Radix (B. P.). Columbo, or Columba, 
is the root of Jateorrhiza Palmata. Its taste is bitter and its odor 
is slightly aromatic. Two alkaloids are found in it, berberine and 
columbine, and a third substance known as calumbic acid. Calumba 
is one of the purest bitters known, as it does not contain tannic acid. 

Therapeutics— Calumba is one of the best simple tonics that can 
be used, owing to its lack of astringent effect and to its favorable 
action on mucous membranes. 

In case of g astro-intestinal atony, particularly that following fevers 
and similar states, calumba will be found of service, and it is a val- 
uable remedy in the convalescent stages of summer complaint and 
serous diarrheas. The following prescription of Dr. George B. Wood 
is very useful in intestinal atony when associated w r ith flatulence, 
although its bulk is disadvantageous and its taste bitter: 

]$ — Pulveris calumbae 5ss (16.0) 

Pulveris zingiberis $ss (16.0) 

Sennse foliorum 3J (4.0) 

Aquae bullientis Oj (480 cc). — M. 

Fiat infusum. 

S. — A wineglassful t. i. d. 

Administration. —The fluidextract (Fluidextractum Calumboe) is 
given in the dose of 15 to 60 minims (1.0-4.0); the tincture (Tinc- 
tura Calumbos, U. S. and B. P.), dose J to 2 fluidrams (2.0-8.0 cc). 
The dose of the infusion Infusum Calumbos, B. P., is J to 1 fluid- 
ounce (16.0-30.0). Liquor Calumbos Concentratus, B. P., is given in 
the dose of J to 1 dram (2.0-4.0). 

CALX. 

Calx (U. S. and B. P.), or Lime, or Oxide of Calcium, is an alka- 
line earth which is incompatible with acids, ammoniacal and metallic 
bases, borates, alkaline carbonates, and astringent vegetable infusions. 
It is prepared by calcining white marble, or the purest varieties of 
native calcium carbonate, and contains, when in the anhydrous state, 



174 DRUGS 

not less than 90 per cent, of pure calcium oxide. It should be kept 
in well-closed vessels, in a dry place. It occurs as hard, white, or 
grayish-white masses, which in contact with the air, gradually attract 
moisture and carbon dioxide, and fall to a white powder; which is 
odorless, and has a caustic taste. It is soluble in about 840 parts of 
water at 25° C. (77° F.), and in about 1740 parts of boiling water. 
It is insoluble in alcohol. It forms readily soluble salts with diluted 
acetic, hydrochloric, or nitric acids. When sprinkled with about 
half its weight of water, calcium oxide becomes heated, and is gradu- 
ally converted into a white powder (calcium hydroxide or slaked 
lime) . When this is mixed with about 3 or 4 parts of water, it forms 
a smooth magma (milk of lime) . 

Therapeutics.— Lime is used for the purpose of acting as an eschar- 
otic, particularly on old ulcers and on hairy growths. It is never 
given internally except in the form of the hydrate, or slaked lime. 
As an escharotic application lime is used in the caustic Potassa cum 
Calce. When given internally it should always be used as Liquor 
Calcis, U. S. and B. P., or lime-water, and under these circumstances 
it acts as an antacid, as an aid to the digestion of milk by preventing 
too rapid and solid coagulation of the casein, and by exciting an 
increased gastric secretion. It is also feebly astringent. Given to 
infants and nursing women, it is probably utilized in the body in 
the formation of bone. It is also of value in diabetes, in the uric-acid 
diathesis, and in the excessive nausea and vomiting often seen in 
adults and children and due to acidity of the stomach. Teaspoonful 
doses of milk and lime-water, equal parts, will often be retained by 
such patients when nothing else will remain in the stomach. 

The dose of lime-water is 1 dram (4.0) to 1 ounce or even 2 ounces 
(30.0-60.0) . Externally applied, lime-water is of value in tinea capitis 
and similar states, and was at one time a popular application in burns, 
when mixed with equal parts of linseed or olive oil, forming Linimen- 
tum Calcis, U. S. and B. P., or Carron oil. Picric acid is much better. 
(See Burns, Part IV.) As a local application in membranous croup 
and diphtheria lime-water has had a high reputation, and is believed to 
dissolve the membrane, but it does not compare in usefulness with per- 
oxide of hydrogen. It may be used as a spray or by means of a swab. 

Liquor Calcis, U. S., or lime-water, is to be made by adding a piece 
of unslaked lime as large as a walnut to 2 quarts of boiled and filtered 
water in an earthen jar; after stirring it thoroughly allow it to settle, 
and pour off the clear liquid into a bottle. More water may then be 
added to the lime until it is all used. 

Calx Chlorinata. 

Chlorinated lime (Calx Chlorinata, U. S. and B. P.) is the hydrate 
of lime, containing 30 per cent, of chlorine, provided it is of official 
strength. It is an exceedingly irritant substance because of the 



CALX 175 

chlorine which it contains, and is never used internally. It occurs 
as a white, or grayish-white, granular powder, exhaling the odor 
of hypochlorous acid, having a repulsive, saline taste, and becoming 
moist and gradually decomposing on exposure to air. 

In water or in alcohol it is only partially soluble. 

Much of the chlorinated lime sold is useless, containing too little 
or no free chlorine. Good chlorinated lime should be so laden with 
the gas that the face cannot be held near it without the eyes being 
severely irritated. Unless the chlorine is present, the lime is of no 
value, for the employment of chlorinated lime as a disinfectant 
depends upon the action of this gas, the lime being used merely as a 
vehicle and oxidizer, the gas by itself being difficult of application. 

As a disinfectant for privies, drains, and sinks chlorinated lime is 
one of the best, if not the best, we possess. A few pounds of it may 
be added every week to the contents of a privy vault with great 
advantage, and a solution of it may be used in bed-pans and urinals. 
When the passages of a patient having typhoid fever are to be 
received in a bed-pan, a chlorinated-lime solution should be placed 
in the receptacle beforehand, so that the fecal matter or urine will 
fall at once into a disinfecting fluid, when the contents of the pan 
should be well mixed. The solution should be of the strength of 
1 pound to 2 gallons. Chlorinated lime should be placed liberally 
over and about decaying animals, and in exhuming corpses sheets 
wrung out in a solution made as directed above will, if wrapped about 
the body, be found of service to destroy the stench. 

Chlorinated lime, in the proportion of a level teaspoonful, rubbed up 
in a cup of water, and then diluted with 3 cupfuls of water, may 
be used to purify and disinfect germ-laden water in the proportion of 
1 teaspoonful of this solution to 2 gallons. This produces no dis- 
agreeable taste in the water, as the proportion of free chlorine is only 
4 to 5 parts in a million, but it is sufficient to destroy in ten minutes 
typhoid and cholera bacilli and the dysentery bacillus. 

Thresh advises that in no case should less than 1 part of chlorine 
be added to 1,000,000 parts of water, and if the water is known to 
be foul, as when derived from a polluted river, 2, 3 or more parts 
should be added. His method is as follows: 

1. Obtain a supply of high quality chlorinated lime in J-pound 
hermetically sealed tins. 

2. A corresponding number of J-pound packets of sodium thio- 
sulphate. This salt (usually called hyposulphate of soda and largely 
used in photography) is nearly tasteless and combines with all the 
available chlorine in about half its weight of chlorinated lime. From 
these the following stock can be quickly prepared : 

3. Add the contents of a tin of No. 1 to 1 gallon of water and 
shake until uniformly mixed. 

4. Add 1 packet of thiosulphate to 1 gallon of water and shake 
until dissolved. 



176 DRUGS 

A gallon of solution No. 3 will sterilize 8000 gallons of any ordinary 
clear well or river water in fifteen minutes, and if at the expiration 
of that time the 1 gallon of thiosulphate solution No. 4 be added to 
the water any excess of chlorine will be eliminated. 

If calcium hypochlorite is obtainable it may be substituted; 15 
grains (1.0) will sterilize 40 gallons of water in half an hour. 

Chlorine fumes will bleach many dyed goods, and therefore colored 
fabrics should not be exposed to them. 

Chlorine gas, in a diluted form, has been used for the treatment of 
aphonia due to cold in cases where the aphonia persists for some 
weeks. It can be liberated by allowing a few drops of hydrochloric 
acid to fall upon chloride of lime or chloride of sodium: 

The placing of chlorinated lime in saucers about sinks and closets 
for the purposes of disinfection is useless. When the chlorine is 
present in a sufficiently concentrated form to kill germs, it will also 
kill the occupant of the chamber. A deodorant effect may be 
obtained, but a bad smell, if it exists, even when overcome by a 
greater one, is not really gotten rid of. 

The official preparations of the B. P. are Liquor Calcis Chlorinate 
and Vapor Chlori. 

Calx Sulphurata. 

Sulphurated lime (Calcii Sulphidum Crudum, U. S., Calx Sul- 
phurata, B. P.) is useful to check inflammation and hasten suppura- 
tion; the dose is J to \ grain (0.015-0.03). It is of great value in acne 
pustulosa and all forms of cutaneous suppuration. When sulphurate 
of lime is not obtainable and successive crops of boils appear it is often 
possible to relieve the patient by baking egg-shells in an oven, pow- 
dering them and then letting the patient eat 1 dram (4.0) or more of 
the powder each day. 

The preparations of the B. P. that are not official in the U. S. are 
the saccharated solution of lime (Liquor Calcis Saccharatus) , dose 15 
to 60 minims (1.0-4.0), and slaked lime (Calcii Hydras), used in 
making different preparations. 

CAMPHOR. 

Camphor (Camphora U. S. and B. P.) is derived from Cinnamomum 
C amphora, which grows chiefly in China and Japan. The camphor 
used in the drug stores is refined camphor, and is obtained by repeated 
sublimation. Camphor should be kept in well closed vessels, in a 
cool place. It occurs in white, translucent masses, of a tough con- 
sistence and a crystalline structure, readily pulverizable in the pres- 
ence of a little alcohol, ether, or chloroform; having a penetrating, 
characteristic odor, and a pungent, aromatic taste. It is soluble in 
1000 parts of cold water and in 1 part of strong alcohol. Camphor 



CAMPHOR 111 

is so volatile that if exposed to the air for any length of time it is 
wholly volatilized. It is an exceedingly combustible substance, burn- 
ing with a smoky flame. It may be white or pinkish in color. 

Physiological Action.— If taken in very large doses, camphor pro- 
duces epileptiform convulsions, preceded by vertigo, roaring in the 
ears, and delirium. The pulse soon becomes rapid, feeble, and run- 
ning, and the skin livid, cold, and covered with sweat. Intense heat 
and burning may be felt in the belly, and, if the poisoning be slow, 
evidences of gastro-intestinal and renal inflammation ensue. In small 
doses it acts as a stimulant and gives a sensation of warmth to the 
stomach, while the pulse may become more rapid and stronger under 
its influence. At the same time there is a sedation of the nervous 
system and a general feeling of contentment. In large medicinal 
dose camphor is thought by some to act as a sexual stimulant, and 
by others as a sexual sedative. The stimulant effect is probably only 
produced by doses large enough to produce irritation of the genito- 
urinary tract. The convulsions following poisonous doses are due to 
the action of the drug on the brain. The drug, although largely 
destroyed in the body, is chiefly eliminated by the kidneys as campho- 
gly curie acid, and also escapes by the breath and the perspiration. 

Therapeutics.— Internal Use.— Camphor is employed for the pur- 
pose of acting as a nervous sedative and antispasmodic in the treat- 
ment of nervous women and children, and as a carminative in indi- 
viduals who suffer from intestinal flatulence. It is of value in nervous 
dysmenorrhea and headache, and is best combined with one of the 
new analgesics, such as antipyrine and acetanilid given in tablet form. 
As it is virtually a volatile oil so far as its physiological action is 
concerned, it will be found useful in cholera and in cholera morbus, 
and in all forms of serous diarrhea, but rarely in mucous diarrhea. 
(See Diarrhea.) In chordee, combined with bromides and similar 
depressants to the spinal cord, camphor is of great service in some 
cases, particularly late in the disease. In adynamic fevers it has been 
used as a diffusible stimulant by Graves and by many others since 
his time with success. Camphor is a very useful remedy in sudden 
depression coming on in the course of acute and prolonged diseases, 
such as croupous pneumonia and typhoid fever. It may be given by 
the mouth or, if the emergency is a pressing one, by hypodermic 
injection. Under these circumstances it is best given in the dose of 
5 grains (0.4) dissolved in almond oil, which should be perfectly sterile. 
Liquid petrolatum should never be used as a solvent as it has often 
caused the development of fibrous tumors and if it enters a vessel 
produces a dangerous type of oil embolism. When used in the 
nervous depression of phthisis, Alexander asserts that its continuous 
injection may result in cumulative action and develop the symptoms 
of mild camphor poisoning; but experience leads me to believe that 
very much larger doses than those hitherto considered wise are often 
efficient. In hiccough it is of great service, and in cardiac palpitation 
12 



178 DRUGS 

due to functional irritability it is of value. In old or atonic cases of 
capillary bronchitis and catarrh of the air-passages it is useful. In 
chronic nasal catarrh spirit of camphor when inhaled from the mouth 
of a vial gives off enough of the drug to stimulate secretion and tone 
up the parts. Camphor water is also of value as a mouth-wash in 
persons who have fetid breath. 

Camphor may be inhaled or taken internally in cases of cold in the 
head, in the early stages, with great relief, and exercises a decided 
influence in aborting the attack. The following formula may be 
employed : 

R— Camphorse gr. v (0.33) 

Extracti belladonnse gr. j (0.06) 

Quininse sulphatis gr. x (0.65). — M. 

Fiant tabellse vel capsular, No. x. 

S. — One every hour for four or five doses. 

After the attack is well developed this is useless, but used early it 
will decrease the frontal headache and the sneezing and running at 
the nose. In coryza from unknown causes with much lacrimation 
and incessant sneezing, camphor will be found of benefit. It may be 
snuffed up the nostril in a fine powder, or powdered camphor may 
be put in boiling water and fumes inhaled. The spirit may also 
be inhaled from a handkerchief. 

Exteenal Use.— Externally camphor may be used as a stimulant 
to indolent sores and as a useful addition in small amount to the pre- 
cipitated carbonate of calcium as a dusting-powder in intertrigo. In 
the form of a liniment camphor is used over inflamed joints from 
sprains or rheumatism, and in myalgia and neuralgia to relieve the 
pain and stiffness. A mixture of camphor and phenol is a useful 
application to burns and small wounds. (See Phenol.) 

Camphorated alcohol, spirit of camphor, is a useful application for 
abortive purposes when used over boils in their early stages, if repeated 
two or three times a day for a few moments at a time. Following 
these applications, the skin should be dried and camphorated oil 
applied. Ringer and Tilt recommend that Eau de Cologne, saturated 
with camphor, be rubbed into the scalp in the drowsiness and head- 
ache of the menopause, and a lotion of equal parts of aqua ammonise 
and spirit of camphor dabbed on the painful or hyperesthetic spots 
at the top of the head, so commonly felt by nervous women at the 
change of life or during menstruation, will be found to give relief. 

Administration.— Camphor is used internally in the form of the 
camphor water {Aqua Camphom, U. S. and B. P.), dose J to 2 fluid- 
ounces (16.0-60.0) ; the spirit of camphor (Spiritus Camphom, U. S. 
and B. P.), dose ^ fluidram (2.0), or in the form of the camphor 
itself, in pill, in the dose of 1 to 3 grains (0.06-0.2) in each pill. 

The best preparation for internal use is the spirit, or the camphor 
itself may be given in pill or capsule. 

For external use we have, official, camphor liniment (Linimentum 



CAMPHOR MONOBROMATE 179 

Camphorce, U. S. and B. P.) and soap liniment, or Linimentum 
Saponis, U. S. and B. P., which is the milder of the two. A com- 
pound tincture of camphor (Tinctura Camphorce Composita), com- 
posed of opium, benzoic acid, camphor, and oil of anise, is official 
in the B. P., dose 15 minims to 1 fluidram (1.0-4.0). This pre- 
paration is practically equivalent to "paregoric." (See Opium.) 
Linimentum Camphorce Ammoniatum, B. P., is composed of camphor, 
rectified spirit, and stronger ammonia. 

CAMPHOR MONOBROMATE. 

Monobromated Camphor (Camphora Monobromata, U. S.) is made 
by heating together in a sealed tube camphor and bromine. It occurs 
in colorless crystals or scales, and has a mild taste resembling cam- 
phor. It is almost entirely insoluble in water, but is freely soluble 
in alcohol, ether, and chloroform. 

Physiological Action.— Monobromated camphor is thought to 
possess powers partaking of the bromides and of camphor, but most, 
if not all, of its effects are due to the camphor alone, because the 
bromide is present in too small an amount to exercise much, if any, 
effect; and, more important still, the bromine and the camphor form 
so stable a compound that they are not disassociated when absorbed. 
In the frog its causes, when given in poisonous dose, loss of reflex 
action, motor palsy and death by respiratory failure, and in warm- 
blooded animals violent convulsions, Cheyne-Stokes respirations, 
muscular tremblings, and weakness. The pulse is at first more rapid 
than normal, then slow and weak, death ensuing in coma or during 
the convulsions. 

Therapeutics.— When combined with other drugs monobromated 
camphor will generally be found useful for pain, particularly in 
lumbago, or the pain due to nervous disturbances. If used in hys- 
terical females, it will often produce sleep, and is of value to those 
who are addicted to the alcohol-habit, as it acts as a sedative and 
warms the stomach. Like camphor itself, it is a gastric irritant, and 
should not be employed where gastritis exists. It has been used in 
spermatorrhea with some success, and in delirium tremens has been 
found of benefit in cases where the gastric mucous membrane is 
depressed and the nervous twitchings are troublesome, but as a ner- 
vous sedative it is too feeble to control the patient's delirium. In 
whooping-cough it may be tried, and it has been used in chorea, 
epilepsy, and petit mal. In the nervous depression and pains of 
epidemic influenza monobromated camphor has been largely used. 
It is not of very great value. 

Administration.— This drug should never be used hypodermically, 
as it is too irritating, but administered in the dose of 5 grains (0.32) 
three times a day in pill, or in an emulsion made by dissolving it in 
six -times its weight of expressed oil of almonds and then forming 
an emulsion with gum-arabic water in the usual manner. 



180 DRUGS 



CAMPHORIC ACID. 



Acidum Camphoricum, made by the oxidation of camphor through 
the influence of acids, is the best remedy for the night-sweats of 
phthisis. In a large number of cases suffering from night-sweats 
the author has found this drug to act very favorably indeed where 
other remedies failed, and he has never seen it produce disagreeable 
symptoms. 

It may be given in the dose of from 20 to 30 grains (1.3-2.0), 
taken an hour or two before the sweat is expected. In very obsti- 
nate cases as much as 60 grains (4.0) should be given, but under 
these circumstances it should be used in two separate doses of 30 
grains (2.0) each, two hours apart, in order to avoid irritating the 
stomach. It is best given in capsule or cachet, as it is insoluble in 
water. In other instances camphoric acid may be given in the fol- 
lowing formula : 

]$ — Acidi camphorici 5iv (16.0) 

Alcoholis fgij (60.0) 

Mucilaginis acaciae f §iij (90.0) 

Syrupi aurantii q. s. ad fgvj (180.0). — M. 

S. — Dessertspoonful (8.0) to a tablespoonful (16.0) one hour before sweat is expected. 

In the writer's experience, camphoric acid is possessed of little 
power in cases of bromidrosis. 

CANNABIS. 

Indian Hemp (Cannabis, U. S., and Cannabis Indica, B. P.) is the 
flowering top of the female plant of Cannabis sativa. It must be noted 
that this is an entirely different plant from Canadian hemp or Apo- 
cynum Cannabinum which in full doses is an intense irritant and 
drastic. The nature of the active principle has never been determined 
with certainty. It is claimed by some to be a resin, by others an oil 
to which the name cannabinol is applied. American-grown Cannabis 
sativa has, however, been proved by Houghton to be equally active 
with imported Cannabis sativa. 

The selection of this drug is attended with certain difficulties 
because of the fact that the unfertilized flowering top of the female 
plant possesses the active constituent in greatest proportion and is 
the part usually chosen for extraction. The fruiting top is propor- 
tionately less active only because the seeds which make up a large 
part of weight of the ripe top, are without activity, as are also the 
stems. The leaves contain the same active agent as the blossoms 
but usually in smaller proportion. 

Physiological Action.— Given in full dose to man, this drug causes 
exhilaration and incessant laughter arising from the slightest cause, 
the person seeming convulsed with merriment; in other cases the 
sensations are disagreeable, and even death may seem imminent to 
the deranged mind. Sometimes the sensation of very full breathing 
comes on, and the patient thinks he is about to burst from the inflation 



CANNABIS 181 

of his lungs. After this, deep sleep ensues, lasting for many hours, 
even as many as fourteen or fifteen, without intervals of wakefulness. 
One of the most constant and marked symptoms in poisoning in man 
is the sensation of prolongation of time, so that minutes seem like 
hours, and, in addition to this, a peculiar separation of the mental 
powers occurs, during which both hemispheres of the brain seem to 
think differently on the same subject. If the dose be very large, the 
respirations are slowed very considerably, but no death from the use 
of cannabis by man is on record, and enormous amounts have been 
given to the lower animals without causing a lethal effect. 1 Applied 
to a mucous membrane, it acts as a severe irritant, and then as a local 
anesthetic, but the primary effect is so powerful as to prevent its 
application to mucous membranes for the relief of pain. 

Therapeutics.— Cannabis is one of the best additions to cough 
mixtures that we possess, as it quiets that tickling in the throat, and 
yet does not constipate nor depress the system as does morphine. In 
advanced phthisis it is justifiable to keep the patient constantly in a 
state of quiet comfort by its use. For the relief of pain, particularly 
that depending on nerve disturbance, hemp is very valuable. Before 
the introduction of antipyrine and its congeners, tincture of gelsemium 
and the tincture or extract of cannabis were our best remedies in 
the treatment of migraine. The gelsemium in such cases should be 
given in full dose, 20 drops (1.3) of the tincture, and be followed by 
10 to 20 drops (0.6-1.3) of the fluidextract of cannabis, it being known 
that the sample about to be used is active. After this dose of gelse- 
mium the patient should be carefully watched, lest he suffer from an 
excessive influence of the drug, as such an amount may produce 
great depression in susceptible persons. In true migraine with 
hemianopsia this treatment is often most effectual in aborting the 
attack. The prevention of further attacks is to be attained by the use 
of smaller amounts of the cannabis during the intervals, the gel- 
semium only being used at the onset of the symptoms. In paralysis 
agitans cannabis may be used to quiet the tremors, and in spasm 
of the bladder, due to cystitis or nervousness, it often gives great 
relief. In sexual impotence, not dependent upon organic disease, 
it is said to be of value combined with strychnine or nux vomica and 
ergot. It acts as a nervous sedative in exophthalmic goiter. 

In headaches at the menopause cannabis is useful, and if the head- 
aches are associated with constipation and anemia, iron and aloes 
should be given simultaneously. Where headaches are due to retinal 
asthenopia sl very useful prescription, according to de Schweinitz, is 
as follows: 

ty — Tincturee nucis vomicae ........ i^ij (8.0) 

Tincturae cannabis f3ij (8.0). — M. 

S. — 15 drops (1.0), in water, twice or thrice a day. 

1 The author has injected as much as 5 drams of a fluidextract, active in the does 
of 10 minims to man, into the jugular vein of a small dog without producing death. 



182 DRUGS 

The following prescription has been found to be very efficient in 
the hands of the author in treating gastralgia and other forms of 
abdominal pain: 

1$ — Tincturae capsici f5j (4.0) 

Tincturae cannabis f gss (16.0) 

Tincturse opii deodorati fgj (30.0) 

Tinctures chloroformi f §j (30.0) 

Tincturae lavandulae compositae . . q. s. ad fgiv (120.0). — M. 

S. — Teaspoonful (4.0) every hour until pain is relieved. 

In cases of uterine subinvolution, chronic inflammation, and irritation 
cannabis is of great value, and it has been found of service in metror- 
rhagia and nervous and spasmodic dysmenorrhea. Not only does it 
relieve pain, but it also seems to act favorably upon the muscular 
fibers of the uterus. 

In acute and chronic Bright's disease cannabis often allays the 
painful sensations over the renal region, and has been recommended 
by some writers in the cases in which bloody urine is present. In 
gonorrhea it is said to decrease the discharge and prevent chordee, and 
it has supplanted the use of copaiba and cubebs in some practitioner's 
hands. It should not be used in the early stages of gonorrhea, but 
in the later or subacute stages. There is some foundation for the 
belief that in small doses it acts as a sexual stimulant. 

The advantages possessed by cannabis are that it does not consti- 
pate nor cause after-depression and nausea. On the contrary, there 
is often an increase rather than a decrease of the appetite under its 
influence. In the Anglo-Saxon race the cannabis habit is practically 
unknown, but in the East Indies when used to excess it sometimes 
causes maniacal insanity, from which the patient nearly always 
recovers after some days, weeks, or months. 

Administration.— The employment of this most valuable remedy is 
handicapped by its frequent lack of power— a fault which is largely 
dependent upon reasons already given. Only a preparation which 
has been physiologically tested should be used. The physician should 
always employ some preparation known by him to be active by per- 
sonal trial before condemning the drug as a failure in a given case. 

The dose of the solid extract (Extr actum Cannabis, U. S. and B. P.) 
is from i to J grain (0.015-0.03), that of the fluidextract (Fluidex- 
tractum Cannabis, U. S.) from 4 to 20 minims (0.25-1.3), and that of 
the tincture (Tinctura Cannabis, U. S. and B. P.) from 15 minims 
to 1 dram (1.0-4.0), 5 to 15 minims (0.3-1.0), B. P. 

CANTHARIS. 

Cantharis (U. S.), or "Spanish Fly," is really a beetle, known 
as Cantharis vesicatoria, and as such appears with iridescent cover- 
ings or wing-sheaths of a bluish or greenish hue. The insects come 
chiefly from Spain, Italy and Sicily, and from the southern parts 
of Russia. Those from Russia are supposed to be the best. Accord- 



CANTHARIS 

ing to Leidy, the vesicating substance is in the blood, thf 
the secretions of the generative apparatus. The blistering 
contains cantharidin, an active principle, which has 
cantharis in the new B. P. 

Physiological Action.— Locally applied to the skin, cantharides 
causes irritation and finally vesication. The blister produced may be 
quite large, and enough of the drug may be absorbed to cause fever 
and nervous excitement. The ingestion of a moderate dose of can- 
tharides produces a sensation of warmth in the stomach and slight 
stimulation of the genito-urinary system, particularly the kidneys and 
urinary tracts. Large amounts produce great pain in the lumbar 
region, a sensation of heat in the bladder and the urethra, priapism, 
agonizing vesical tenesmus, widespread acute nephritis, bloody urine, 
which is scanty at first, and finally suppressed, with great irritation 
of the external openings of the genito-urinary apparatus. The inflam- 
matory changes may cause sloughing of the penis or of the labia in 
the female. 

Violent gastro-enteritis is nearly always a pressing condition. A 
diagnostic sign of cantharidal poisoning, when the beetles have been 
swallowed, is the appearance of pieces of the iridescent wing-sheaths 
or coats in the vomit. Thirst is always a prominent symptom of 
poisoning by cantharides. 

Therapeutics.— Cantharides are employed internally and externally. 
When given by the mouth the tincture is used as a uterine stimulant, 
to affect the uterine mucous membrane and relieve amenorrhea in cases 
in which atony and depression are the cause of the depression. Some 
persons teach that the tincture of cantharides is a valuable remedy in 
small doses in the second stage of acute desquamative nephritis, but in 
the instances where the writer has seen it used it has aggravated the 
condition, although it is supposed to decrease the excretion of the albu- 
min and blood. In the later stages, where the kidneys are relaxed 
and torpid or where albuminuria comes on on the slightest exertion, 
tincture of cantharides in the dose of \ minim (0.025) three times a 
day is of service. 

In cases • of chronic parenchymatous nephritis, particularly where 
alcoholism is the cause of the disease and the kidneys are inactive, can- 
tharidal tincture is sometimes used. In pyelitis and in chronic cystitis 
it is of service, and it has been recommended highly in drop doses. The 
use of cantharides is of value in incontinence of urine of a minor degree, 
as that occurring in elderly or nervous females when coughing, sneezing 
or laughing, and will often give relief after years of suffering. In chor- 
dee, in the dose of f minim (0.025) twice or thrice daily, it is some- 
times of service. For impotence depending upon sexual excess Ringer 
asserts that the use of 5 to 8 minims (0.3-0.5) of the tincture of 
cantharides, with full doses of the tincture of the chloride of iron and 
nux vomica, will often relieve the patient and enable him to beget 
children. This dose of cantharides must be given with caution. The 



184 DRUGS 

drug has no true aphrodisiac influence even when given in almost 
toxic dose. In gleet of a very chronic type and in prostatorrhea it is of 
service. Dermatologists have used cantharides internally as a remedy 
in psoriasis, eczema, lichen, and prurigo, with asserted great success. 
The dose should not be large enough to irritate the stomach or kidneys. 

Externally, cantharides are used in the production of blisters for 
the purpose of causing the absorption of effusions or as a counter- 
irritant of some severity in cases of deep-seated inflammations. (See 
Counterirritation.) Care should be taken that a sufficient amount of 
the drug is not absorbed to cause strangury and renal irritation. In 
renal congestions and inflammations the use of cantharides as a coun- 
terirritant is often contraindicated because of this danger. Huchard 
and others have reported cases in which, without the disease of the 
kidneys, a cantharidal blister has produced violent acute nephritis, 
with resulting uremia. In proportion of \ minim (0.025) of the tinct- 
ure of cantharides to 40 minims (2.6) of water it is said to be an 
efficient application for burns, but how it acts is not known. 

Administration.— The dose of the tincture (Tinctura Cantharides, 
U. S. and B. P.) is from f to 5 minims (0.025-0.3), and it is the only 
preparation used internally. The cerate (Ceratum Cantharides, U. S.) 
is used, spread upon muslin, to produce a blister, and the cerate of the 
extract, which is no longer official, is used for the same purposes and in 
the same manner. The cantharidal collodion (Collodium Cantharida- 
twm, U. S.j Collodium Vesicans, B. P.) is a method of applying the 
blister which is most cleanly, but there is more danger of absorption 
of the drug if it is used. Emplastrum Cantharidis, U. S., is also 
official. Liquor Epispasticus, B. P., is employed as a counter- 
irritant. • 

"Warming plaster" (Emplastrum Picis Cantharidatum) is a mild 
counterirritant plaster to be employed where a blister is thought to 
be too severe. The preparations of the B. P. other than those 
named are Emplastrum Caniharidini and Unguentum Cantharidini. 

The unofficial plasters of cantharides are the best pareparations to 
use for the production of a blister. In order to obtain a perfect effect 
the skin should be washed thoroughly with soap and water and dried 
with a towel, which should be rough enough to produce reddening of 
the cuticle. After this the skin should be moistened with vinegar, 
and while wet the blister is to be applied. 

CAPSICUM. 

Capsicum, U. S., Capsici Fructus, B. P., or Cayenne Pepper, is the 
fruit of Capsicum fastigiatum a native of tropical Africa and of 
Central America. It occurs in long ovoid pods, which, when ripe, 
are scarlet red and possess a very hot, burning taste. The active 
principle is capsicine, which is a dark reddish liquid, and which is a 
volatile alkaloid. 



CAPSICUM 185 

Physiological Action.— Locally applied to the skin or mucous mem- 
branes capsicum causes redness, and finally, in the case of mucous 
membranes, vesication. The alkaloid will also produce these changes 
in the skin. When used internally for any length of time in excess 
capsicum will cause a chronic or subacute gastritis with pain and 
discomfort over the liver and stomach. If single large doses are 
used, renal irritation and inflammation ensue, with strangury and 
the passage of concentrated urine. 

Therapeutics.— In cases of atony of the stomach due to general 
debility, errors in diet, and alcoholism of the chronic type capsicum 
is one of the best remedies we have. When the patient is suffering 
from acute alcoholism the gastric mucous membrane is often too 
much irritated to permit of its use, but after the lapse of some days 
it may be found of benefit for the purpose of increasing the digestive 
power. As a remedy for subacute alcoholism it is useful, since by its 
stimulating effect and hot sensation it often satisfies, at least to 
some degree, the craving for alcohol. Under these circumstances it 
should be used in the dose of 3 to 5 minims (0.2-0.3) of the tincture 
every four or five hours, or as the oleoresin in pill in the dose of 
J to 1 grain (0.03-0.06). The following prescription has been found 
of great service in these cases: 

]$ — Tincturse capsici f 3iss (6.0) 

Tinctura opii deodorati f 3ij (8.0) 

Spiritus chloroformi f5j (30.0) 

Tincturse lavandulae compositse . . q. s ad f5iv (120.0). — M. 

S. — Dessertspoonful (8.0) every four or five hours. 

In the flatulent colic of old persons and young adults capsicum will 
be found not only to act as a carminative, but also to prevent the 
development of the gas. Sometimes in the anorexia of convalescence 
capsicum acts most favorably. In chronic nephritis it is of consider- 
able service, and tends to check albuminuria, but it is only to be used 
in the chronic forms and stages of renal disease or in the treatment 
of functional torpidity of the kidney. The tincture is to be given 
under these circumstances in the dose of 10 minims (0.6) or less, but 
in some cases which are very chronic as much as 20 minims (1.3) 
may be used. In sore-throat and simple tonsillitis the tincture of 
capsicum and glycerin, half and half, form a very useful local appli- 
cation applied by means of a swab. The same preparation may be 
used as a gargle for relaxed uvula and chronic pharyngitis. 

Capsicum may be used as a gastro-intestinal stimulant to aid in 
the absorption of other drugs. Applied externally, capsicum acts as 
a counterirritant, producing redness of the skin, but not a blister, 
in the ordinary individual. It is one of the best moderate counter- 
irritants which can be used. Capsicum plaster (Emplastrum Capsici, 
U. S.) is useful in lumbago and rheumatism when placed over the 
affected muscles, and in headache when applied to the nape of the 
neck. The tincture is sometimes painted over chilblains which are 



186 DRUGS 

unbroken. The following method, given by Ringer, is very effica- 
cious in this annoying affection: 

"Make a strong tincture of capsicum-pods by steeping them for 
several days in a warm place in twice their weight of rectified spirit 
of wine. Dissolve gum arabic in water to about the consistence of 
treacle. Add to this an equal quantity of the tincture, stirring 
together with a small brush or a large camel' s-hair pencil until they 
are well incorporated. The mixture will be cloudy and opaque. 
Take sheets of silk or tissue-paper; give them, with the brush, a coat 
of the mixture; let them dry, and then give another coat. Let that 
dry, and if the surface is shining, there is enough of the peppered 
gum; if not, give a third coat. This paper should be applied in the 
same way as courtplaster to chilblains that are not broken and 
burns that are not blistered, and it will speedily relieve the itching 
and pain. It acts like a charm and effects a rapid cure. The same 
is true of discolored bruises. It likewise allays rheumatic pains in 
the joints." 

The dose of capsicum is 1 to 5 grains (0.06-0.32) in powder, or 
food or in pill. The dose of the tincture of capsicum (Tinctura Cap- 
sici, U. S. and B. P.) is 5 to 20 minims (0.3-1.3), and of the oleoresin 
(Oleoresina Capsici, U. S.), i to J minim (0.015-0.025). The dose of 
the fluidextract (Fluidextractum Capsici) is 1 to 3 minims (0.05-0.2). 
The plaster (Emplastrum Capsici, U. S.) is useful for external applica- 
tions. An ointment (Unguentum Capsici) is official in the B. P. 



CARBON (CHARCOAL). 

Carbo Ligni, U. S. and B. P., or Charcoal, is prepared by the 
exposure of soft wood to a red heat, air being prevented from coming 
in contact with the wood during the process. Charcoal when used 
for medicinal purposes should be a black, brittle, somewhat shiny, 
porous substance, devoid of taste and odor, and completely insoluble 
in water. 

Therapeutics.— Charcoal is used externally as an application to old 
sores and sloughs to act as a deodorant and antiseptic. These things it 
accomplishes by the absorption of any liquids which may be present, 
thereby depriving germs of a nidus, and by its distinct oxidizing 
power. It may be applied in the form of a dry powder or in a poul- 
tice, which is, however, so uncleanly that other antiseptic dressings 
are preferable. 

The poultice (Cataplasma Carbonis), if used, should be made in 
the following manner: Take of powdered wood charcoal \ ounce 
(16.0), bread-crumbs 2 ounces (60.0), linseed meal \\ ounces (45.0), 
and add boiling water 10 fluidounces (300.0). Macerate the bread- 
crumbs and meal for ten minutes over a fire, and then stir in the 
charcoal to the extent of half the amount just named. Spread out 



CARDAMOM 187 

the poultice and sprinkle the remaining half of the charcoal over its 
surface, and apply while hot to the part affected. 

Internally, charcoal is used in powder in many conditions, and 
acts very well indeed in cases of so-called "sour stomach" from which 
eructations of gas or sour liquids take place. 

The following prescription will also be found useful in the atonic 
or subacute gastric catarrh of persons who are careless in eating and 
who have much belching: 

1$ — Oleoresinse capsici gtt. x vel xx (0.6-1.3) 

Pancreatine gr. xx (1.3) 

Pulveris zingiberis gr. xl (2.6) 

Pulveris carbonis ligni gr. xl (2.6). — M. 

Pone in capsulas, No. xx. 

S. — One or two t. i. d. with meals. 

As ordinary charcoal is not always obtainable, it may be sub- 
stituted by pieces of very thin toast burnt through and through 
until they resemble charcoal. If the attack is very severe and 
vomiting eventually ensues, the ejecta will commonly be found to 
be odorless and not sour, and the stools will also be almost odorless, 
though black. In fermentative and acid diarrheas in adults this 
method of treatment is often of value, the prescription given above 
being a valuable means of cure. When charcoal is used in any 
condition associated with irritation of the mucous membranes of 
the gastro-intestinal tract, it should always be very finely pulverized, 
and if the stomach or bowels are inflamed the capsicum must be 
excluded from the prescription.. 

As a filter for impure water, charcoal, in mass or in powder, is one 
of the most satisfactory substances we have. 

CARDAMOM. 

Cardamom (Cardamomi Semen, U. S.) is the seed of Elettaria 
repens, and is a bitter tonic possessing some aromatic properties. It 
is useful in cases of atony of the stomach and small intestines, particu- 
larly if combined with a mineral acid or some other bitter tonic, 
such as gentian. Cardamom is official in the B. P. as Cardamomi 
Semina. 

If the intestine is atonic and secretion is deficient, the following 
prescription will be found of value: 

3— Acidi nitrici diluti f 5J (4.0) 

Tincturse cardamomi compositae . . q. s. ad f§vj (180.0). — M. 
S. — Dessertspoonful (8.0) after each meal. 1 

Administration.— The official preparations of cardamoms are the 
tincture of cardamoms (Tinctura Cardamomi, U. S.), dose 1 to 2 
drams (4.0-8.0); and the compound tincture (Tinctura Cardamomi 

1 While the rule that an acid is incompatible with a tincture is not recognized in 
this mixture, the quantities of acid and alcohol are so disproportionate that ether in 
any amount is not developed. 



188 DRUGS 

Composita, U. S. and B. P.), which is to be given in the same dose as 
the tincture. This tincture also contains cochineal, cinnamon, cara- 
way, and glycerin. Cardamom is also a constituent of the official 
aromatic powder (Pubis Aromaticus, U. S.). 

CASCARA SAGRADA. 

Cascara Sagrada (U. S. and B. P.) is the bark of Rhamnus Pursh- 
iana, a plant growing in California. It is sometimes called Cali- 
fornia buckthorn, to distinguish it from ordinary buckthorn or 
Rhamnus Frangula, which it closely resembles in many ways, and 
which may be used as a substitute for cascara sagrada in some cases. 

Therapeutics.— Cascara sagrada ought never to be used as a purge, 
but only as a laxative. It is by far the best remedy we have when 
employed simply to empty the bowel of fecal matter in cases of 
constipation, since it not only performs this function without intes- 
tinal disturbance, but also simultaneously acts as a tonic to the 
intestine, and so prevents the constipation which usually follows 
the use of all other drugs of its class. 

In the United States cascara sagrada is most commonly employed 
in the form of the fluidextract (Fluidextractum Cascara? Sagrada?, 
U. S., or Extractum Cascara? Sagrada Liquidum, B. P.), in the dose 
of from 10 to 20 minims (0.6-1.3), J to 1 fluidram (2.0-4.0), B. 
P., at night or morning and night. If 20 minims (1.3) fail to act 
30 minims (2.0) may be used; but if larger doses are required, other 
drugs should be employed as adjuvants, as fluidram doses of the 
fluidextract of cascara may produce irritation of the bowel, and 
enteritis or intestinal catarrh. The objection to cascara sagrada 
is its bitter taste, which may be partially disguised by the additional 
use of Syrupus Aurantii, in the proportion of 1 part of the cascara 
extract to 2 parts of the syrup of orange peel, or the aromatic fluid- 
extract of cascara sagrada (Fluidextractum Cascara? Sagrada? Aromat- 
icum, U. S.), may be given in the dose of from 10 to 30 minims 
(0.6-1.3). The B. P. has a preparation, Syrupus Cascara? Aromaticus, 
which is given in the dose of J to 2 drams (2.0-8.0). 

Some of the preparations of this drug are now made in an almost 
tasteless form, such as "Cascara Cordial/' an aromatic preparation 
useful for children who are constipated, or the non-bitter fluid- 
extract made by a prominent firm in the United States and called 
"Cascara Evacuant," and used in the dose of 20 minims (1.3). The 
solid extract (Extractum Cascara? Sagrada?, U. S.; Extractum Cas- 
cara? Sagrada? Siccum, B. P.) is given in the dose of 2 to 8 grains 
(0.12-0.5). 

CASTOR OIL. 

Castor Oil (Oleum Ricini, U. S. and B. P.) is a fixed oil derived 
by expression from the beans of Ricinus Communis, a plant of the 



CASTOR OIL 189 

United States and elsewhere, but originally derived from India. It 
contains an acrid substance, ricin oleic acid. 

Physiological Action.— The manner in which castor oil purges is 
somewhat in doubt, but its activity probably depends upon the pres- 
ence of ricinoleic acid set free by the alkaline juices of the intestine 
and the fact that it is an oil. 

As is well known, oils— such as olive oil, for example— if given in 
considerable quantity, tend to move the bowels, and the ricinoleic 
acid, which is somewhat acrid, stimulates the small and large gut, 
and so develops peristaltic movement. That this acid possesses 
purgative properties of itself seems proved by the fact that the oil 
will purge when it is rubbed on the skin, and that nursing mothers on 
taking the oil may eliminate the acid in the milk to such an extent 
that the suckling is purged. According to the studies of Rutherford 
and Vignal, the oil has no effect over biliary secretions other than 
that violent purgation indirectly increases the flow, and the researches 
of Hess have shown that the oil acts more rapidly in the small than 
in the large gut, and produces peristalsis only by coming in contact 
with the mucous membrane. 

Therapeutics.— Castor oil is the blandest and most unirritating 
purge we have, with the exception of the sulphate of magnesium, 
which is depletant and much more rapid in its effects. While 
Epsom salt will act in one-half to one hour if the stomach is empty, 
castor oil will generally act in four hours, or perhaps five. 

Castor oil is used whenever irritant materials, such as bad food, 
putrid flesh or decaying or green vegetables, have been eaten, even 
if the inflammation set up after them is very active. If hard bodies, 
such as broken cherry-stones, have been swallowed, castor oil is a 
far better purge than sulphate of magnesium, as it is more gentle 
and lubricates the gut, thereby preventing scraping and irritation. 
Where mucus has accumulated in the bowel in children, and must 
but gotten rid of before other treatment is resorted to, castor oil 
should be used. 

Previous to parturition it has been largely used to relieve the 
bowels of fecal matter, and is said by some practitioners to make the 
labor easier than if any other purge is used. It is also employed 
in the constipation following acute diseases and in that occurring in 
infants and children. 

_ The disadvantages of castor oil lie in its taste, the fact that it is 
oily, that it tends to produce hemorrhoids if used constantly, and 
finally, that its frequent use, or even a single dose, is generally 
followed by more obstinate constipation than existed before, so that 
the dose must be rapidly increased in size to be effective. This is 
one of the reasons why it is useful in irritative diarrheas, for, having 
swept out the mucus and offending matter, it checks the movement 
of the bowels afterward. The purgative effect of castor oil is very 
much increased if a little bicarbonate of sodiumjisf given with it. 



190 DRUGS 

A very effective purge in very obstinate constipation consists of 
1 ounce (30.0) of castor oil with 1 ounce (30.0) of aromatic syrup of 
rhubarb. 

Some cases of severe neuralgic headache may be cured by the use 
of small daily doses of castor oil. How it acts is not known, unless 
it unloads the bowels and so prevents toxemia, which in turn has 
caused nervous irritation. 

Castor oil, to which has been added a few drops of balsam of Peru 
or oil of eucalyptus, when placed freely on gauze is an excellent 
dressing for ulcers, wounds, and burns. 

Administration.— Castor oil is very much less disagreeable to the 
taste if pure than if poorly prepared. It is also true that too great 
purification renders it less active. 

The methods directed for taking castor oil are as various as the 
tastes of individuals. Its odor may be masked by a drop or two of 
the oil of bitter almonds, but emulsions of the oil are not of any 
service, save to interfere with its efficiency. Some take oil in the 
foam of beer or porter, others in syrup of sarsaparilla and soda-water, 
and still others in milk or cream. A good way to take it is to eat 
one or two strong so-called cream peppermint drops, or even the crys- 
talline peppermint drops, swallow the oil from a spoon which is to be 
placed well back in the mouth, and immediately eat several other 
peppermints. This plan is improved by using the oil in milk or 
water, so that the liquid carries the oil down into the esophagus 
without its touching the mucous membranes. It may also be taken 
in highly seasoned beef -tea. Ringer recommends the following: | 
ounce (16.0) of oil, fresh syrup of acacia 3 drams (12.0), and distilled 
water 5 drams (20.0), flavored with a little oil of lemon or pepper- 
mint. Wood advises that it be mixed with glycerin, equal parts, to 
which is added a drop or two of oil of cinnamon. Ritter advises 
the following formula: 

1$ — Saccharini gr. ii (0.12) 

Olei menthse piperita gtt. v (0.30 

Alcoholis q. s. fiat solutio. 
et adder 

Oleiricini f Sviii (240.0) 

Sig. — One or two tablespoonfuls as needed. 

or, 

^ — Saccharini gr. \ (0.015) 

Vanillini gr. \ (0.008) 

Olei cassise TT1J (0.065) 

Alcoholis TTlxv (1.0) 

Oleiricini fgij (60.0).— M. 

Sig. — Two to four tablespoonfuls as needed. 

By far the best way of administering it is in soft capsules contain- 
ing from \ to 1 dram (1.0-4.0). Most persons can swallow as much 
as a teaspoonful in capsule, and several capsules containing this 
quantity, or a smaller amount, may be given at once to complete 



CHENOPODIUM 191 

the necessary dose. The capsules should be dipped in water in 
order to render them slippery and so more easily swallowed. 

The dose of castor oil for an infant is 1 to 2 fluidrams (4.0-8.0), 
and for an adult § to 1 fluid ounce (16.0-30.0). Often, however, small 
doses will act when it is desired to sweep out of the bowel foreign 
matter that is causing diarrhea. 

Owing to the fact that the oil will very frequently produce griping, 
a few drops of laudanum should be added to it, or tincture of bella- 
donna may be used. If these cannot be employed, a drop of the 
oil of cinnamon is equally useful for this purpose. 

Under the name of Mistura Olei Ricini the B. P. recognizes a 
mixture of castor oil made into an emulsion and given in the dose 
of 1 to 2 fluidounces (30.0-60.0). 

CATECHU. 

(See Gambir.) 

CAUSTIC POTASH. 

(See Potassium Hydroxide.) 

CAUSTIC SODA. 

(See Sodium Hydroxide.) 

CERIUM OXALATE. 

Cerium Oxalate (Cerii Oxalas, U. S.) is a white granular powder, 
permanent when exposed to the air, odorless and tasteless, and 
insoluble in water and alcohol, but freely so in hydrochloric acid. 

Therapeutics.— Cerium oxalate is often used instead of, or combined 
with, bismuth in the treatment of vomiting, and in some cases of gastric 
acidity. The dose is from 2 to 5 grains (0.12-0.3), given in pill-form 
every four or five hours. 

CHENOPODIUM. 

Chenopodium is the fruit of Chenapodium ambrosiodes, or Ameri- 
can wormseed. The seeds contain a volatile oil and have a distinct 
and rather disagreeable aromatic odor. The oil (Oleum Chenopodii, 
U. S.) is a most efficient remedy for Ascaris lumbricoides , or round- 
icorm. Recent tests show that this oil is often even better than 
thymol in uncinariasis, and its efficiency, unlike thymol and aspidium, 
seems to be increased by castor oil. The dose for an adult is 15 to 
20 minims (1.0-1.3). The dose is 10 minims (0.6) to a child of five 
years either on sugar or in an emulsion made with acacia. If the 
patient is old enough, capsules may be used. The drug if too freely 



192 DRUGS 

given is distinctly poisonous. The general dietetic measures adopted 
for the removal of worms should be insisted upon before the drug 
is given and a saline purge administered one hour after the drug is 
swallowed. (See article on Worms.) 

CHLORAL HYDRATE. 

Although the name Chloral is applied to the substance used in 
medicine, chloral itself is never so employed, hydra ted chloral (Chlor- 
alum Hydration, U. S.; Chloral Hydras, B. P.) being the real prepa- 
ration. Hydrated chloral is a white, crystalline body, but is often 
sold in irregular broken masses, which are generally impure. It 
should be kept in tight bottles in a cool, dark place. It is freely 
soluble in water, alcohol, or ether; also in chloroform, benzene, petro- 
leum benzin, carbon disulphide, fixed and volatile oils. It liquifies 
when triturated with about an equal quantity of camphor, menthol, 
thymol, phenol, or antipyrine. 

Physiological Action.— When chloral is applied to a mucous mem- 
brane, it causes distinct reddening and burning pain, and finally 
acute inflammation. It is, therefore, a local irritant. Chloral acts 
in the body as chloral, and is not broken up into formic acid and 
chloroform, as was taught at one time. 

Nervous System.— In medicinal and toxic doses chloral produces 
sleep by quieting the intellectual centers in the brain, at the same 
time depressing the motor tract of the spinal cord and the motor 
nerves. It also depresses the motor area of the cortex. In medicinal 
amounts it does not decrease sensation, but in toxic doses it does. 
Very often hyperesthesia of the skin results from small doses. Reflex 
action is decreased by its sedative influence on the motor portions 
of the spinal cord. 

Circulation.— A dose of 10 to 20 grains (0.6-1.3) in the healthy 
adult rarely causes any circulatory change, but larger amounts pro- 
duce a fall of arterial pressure due to depression of the vasomotor 
centers, and a slow, feeble, or sometimes a rapid-running pulse, due 
to a direct depression of the heart-muscle, for chloral in overdose is 
a cardiac paralyzant. 

After death from chloral the blood may be found dark and grumous 
looking, with the corpuscles broken down, but these changes occur 
only after very large doses. 

Respiration.— In moderate amounts no respiratory effect is felt, 
but in toxic doses the breathing becomes slower and slower and more 
and more shallow, until it stops in death. When death is caused 
by chloral it is primarily due to centric respiratory failure, but there 
is an almost simultaneous arrest of the heart. 

Temperature.— Chloral tends to lower bodily heat, and in large 
doses produces a marked fall of temperature, which does much 
toward causing death. Brunton has found that animals will survive 



CHLORAL HYDRATE 



193 



very large doses of the drug if external heat is supplied to them. The 
fall of temperature is, at least in part, due to failure of the circulation 
and to vascular dilatation. 



Fig. 20 



Fig. 21 





Fig. 23. 



Fig, 22. 




B 





Fig. 20. — A, chloral causes sleep by quieting intellectual centers in brain. 
Fig. 21. — B, depresses motor centrifugal tracts of cord; C, depresses motor nerves; 
D, does not depress the muscles. 
Fig. 22. — E, depresses heart muscle. 
Fig. 23. — F, depresses the respiratory center in the medulla. 



Kidneys, Tissue-waste and Elimination.— Chloral is elimi- 
nated by the kidneys in combination with glycouronic acid in the 
form of urochloric acid, and, if given in excess, as chloral. Poison- 
ous doses irritate these organs, and may produce bloody urine, owing 
to the nephritis which is set up as the drug passes through the renal 
structures. After chloral is ingested, the urine of a patient will often 
react to Fehling's and Trommer's test for sugar. 

Poisoning.— When a poisonous dose of chloral is taken, the individ- 
ual soon falls asleep and then sinks into a deep coma. The respi- 
rations become at first slow and labored, then shallow and feeble. 
The pulse, at first perhaps a little slowed, soon becomes thready and 
shuttle-like, and is finally lost at the wrist. The face is white and 
livid, the forehead and the hands covered with a cold sweat, and the 
13 



194 



DRUGS 



pupils, which are at first contracted, soon become widely dilated. 
Absolute muscular relaxation is present, and it is impossible to 
arouse the patient. 

Very large doses of chloral have been swallowed and retained 
without causing death. Acher has recorded a case in which 330 
grains (22.0) of chloral and the same amount of bromide of potas- 
sium were taken at one dose with the recovery of the patient, and 
Daley has recorded an instance in which recovery followed a dose 
of 595 grains (40.0). 





ii 



u 



U 



U 



ni 



JU U U [} \J 



u \J 



Fig. 24. — Shows the effect of digitalis in raising blood-pressure and pulse-force in 
chloral poisoning (after Schmiedeberg) : In J the pressure is very low because of the 
effect of a large dose of chloral; the blood-pressure is 40; in II, after the injection of 
digitalis, it is 60; and in III it is 125 and the individual pulse-beat is far stronger than 
before. 



Treatment of Poisoning.— The physician should apply external 
heat and use emetics in the early stages, or, if the case is seen too late 
for emetics to act because of systemic depression, he should use the 
stomach pump. This latter means of removing the drug from the 
stomach is safer and more reliable, because the production of vomit- 
ing may result in efforts which will strain the heart. Strychnine 
should be given in full dose, 2V to T V grain (0.003-0.006), to stimulate 
respiration and the vasomotor system, and atropine may be used for 
the same purpose. The heart is to be supported by half-grain (0.03) 
doses of " digitalone" given hypodermically until some effect is noted, 
but, as digitalis is rather slow in its action, it should be preceded by 
ether and ammonia or brandy or whisky. The patient must not 
raise the head to vomit, and the head should be placed on a lower 
level than the heels to aid in maintaining the circulation of blood in 
the vital centers at the base of the brain. 



CHLORAL HYDRATE 195 

In Chronic Poisoning by chloral or in cases in which the patient 
has come to use the drug as a habit the patient suffers from weak- 
ness, mental and physical, with sudden flushings due to vasomotor 
disorder, from palpitation of the heart, and finally from petechial 
eruptions, bed-sores, ulcerations and sloughs. 

Therapeutics.— Chloral is one of the purest hypnotics that we 
have, and may therefore be used where simple nervous insomnia is 
present, but not when sleeplessness is due to pain. When pain is 
present it is to be employed in the combination of 10 grains (0.6) of 
chloral with f grain (0.01) of morphine, as a much more powerful 
hypnotic effect is produced by the combined action of the two drugs 
than by the use of either one of them alone. 

The following prescription may be used: 

R— Chiorali hydrati 5ij vel iv (8.0-16.0) 

Morphinae sulphatis gr. ij (0.12) 

Syrupi lactucarii f5ij (60.0) 

Aquae destillatae q. s. ad fgiij (90.0).— M. 

S. — Dessertspoonful (8.0), in water, at 10, and at 11 p.m. if necessary. 

Another formula is found on the next page. 

In tetanus and strychnine-poisoning chloral is one of the best 
remedies we have, as it depresses the motor tract of the spinal cord. 
In such a case it should be given in 20-grain (1.3) doses combined 
with 60 grains (4.0) of bromide of potassium. If the convulsion 
prevents deglutition or is brought on by swallowing, these remedies 
should be used by the rectum dissolved in starch-water; and if the 
spasm expels them from the rectum, the patient should be chloro- 
formed long enough to allow the injection to be given and absorbed. 
The same remedies in small doses are to be used minfantile convulsions, 
and in infantile colic in the dose by the mouth of \ to 1 grain (0.03- 
0.06) of chloral to 2 grains (0.12) of bromide of potassium or sodium 
in a teaspoonful of peppermint-water and syrup. In chorea, paralysis 
agitans, and delirium tremens chloral is of great service, but must be 
given cautiously in the last-named condition, for fear it may depress 
the heart, which is already diseased by alcoholic excess. Cases are 
on record in which chloral has caused sudden death from cardiac 
failure in alcoholics with fatty heart— an accident the liability to 
which is increased by the fact that owing to the addiction of the 
patient to a narcotic drug it requires large doses of the chloral to 
produce sleep. In uremic convulsions chloral has been highly extolled, 
but if any acute renal trouble is present, it must not be used lest it 
irritate the kidneys. In puerperal convulsions not dependent upon 
nephritis 20 to 30 grains (1.3-2.0) of the drug may be given, and 
repeated in one or two hours. 

Hiccough, nocturnal epilepsy, and whooping-cough are all indica- 
tions for its use, but in asthma it rarely does good, and if pushed is 
dangerous to the heart. 



196 DRUGS 

Probably because of its counterirritant properties chloral is some- 
times used locally over neuralgic nerves as follows: 

^ — Chlorali hydrati gr. c (6.5) 

Camphorae 5vj (24.0) 

Olei gaultheriae f 3j (4.0) 

Alcoholis q. s. ad fgj (30.0) 

Untoward Effects.— Chloral sometimes causes nausea, purging, and 
vomiting by reason of its irritant action. In susceptible persons 
doses of 10 to 15 grains (0.6-1.0) have produced marked redness and 
swelling of the conjunctiva. Sometimes the last-named symptoms 
are only produced when an alcoholic beverage is taken simulta- 
neously. In still other cases an erythematous, papular, urticarial, 
vesicular, or petechial eruption may ensue, the latter forms being 
seen as a rule in cases of chronic chloralism to which the drug is given. 

Administration.— Chloral is best given in syrup of acacia, simple 
syrup, or water. It should always be well diluted. The syrup of 
chloral (Syrupus Chloral, B. P.) is given in the dose of | to 1 fluid- 
dram (2.0-4.0). The following prescription is useful in insomnia. 

I^— Chlorali hydrati 3J vel ij (4.0-8.0) 

Potassii bromidi 3ij (8.0) 

Syrupi pruni virginianae f5J (30.0) 

Aquae destillatae q. s. ad f 5iij (90.0). — M. 

S. — Dessertspoonful (8.0) in water at night. 

Sometimes chloral can be well given in junket by adding it to a 
liquid rennet, and then adding the rennet to the milk. (See Junket, 
Part III.) 

It is well to remember that if soluble salts like the bromides of 
sodium or potassium are placed in a prescription which also contains 
alcohol, chloral alcoholate may be found which is very irritating to 
the stomach. Alcohol should therefore be avoided, if possible, in 
such prescriptions. 

The question as to the safe dose of chloral is one largely governed 
by the susceptibility of the patient, but alarming symptoms have 
followed a dose of 30 grains, and death after from 30 to 45 grains. 
Thirty grains in twenty-four hours are certainly ample in most cases. 

CHLORAL FORMAMIDE (CHLORALAMINE) . 

Chloral formamide (Chloral formamidum, B. P.) is a compound 
formed by the addition of formamide to anhydrous chloral, and is a 
colorless crystalline substance without odor and of a somewhat bitter 
taste. It is soluble in 19 parts of water and 1.6 parts of alcohol. 
Chloral formamide keeps well in watery solution without decomposi- 
tion. Its physiological action is closely allied to that of chloral, 
except that it is not quite so depressing to the circulation. Upon the 
nervous system it acts chiefly upon the brain and spinal cord, and 
produces sleep — a result to be expected, since both chloral and for- 



CHLORETONE 197 

mamide are hypnotics. It is said not to irritate the stomach and 
kidneys, but it probably is only less irritant than chloral. 

Therapeutics.— Chloral formamide may be employed in medicine 
whenever chloral may be used. It is decidedly a nervous sedative, 
and in the wakefulness of nervous insomnia is very useful. Sleep 
generally ensues about thirty or forty-five minutes after it is taken. 
According to most of the reports published so far, the drug relieves 
pain as well as produces sleep, and is therefore distinct in its action 
from chloral. In neuralgia it is very useful, and it has been found 
of value in the pains of tabes dorsalis. The dose is 10 to 30 grains 
(0.6-2.0), which may be repeated in three or four hours, although 
the sleep generally lasts five to eight hours. The following formula 
may be used for its administration: 

]$ — Chloralformamidi gr. xl (2.6) 

Acidi hydrochlorici diluti Hlv (0.3) 

Syrupi f5ij (8.0) 

Aquae destillatae fgij (60.0). — M. 

S. — Take in two doses in a little water. 

The late Professor Charteris claimed very extraordinary results in 
the treatment of seasickness by the use of equal parts of chloral form- 
amide and bromide of potassium. He gave it in the dose of 30 grains 
(2.0) with an equal amount of the bromide. It is necessary for the 
patient to take a cholagogue for two days before starting on the 
voyage, and as soon as he boards the ship to take the dose named 
on an empty stomach, and at once go to bed and sleep. If this is 
done, Charteris claimed that the patient will awake feeling bright 
and well, and remain so for the rest of the voyage. This combination 
under the name of "chlorobrom" has been also largely used as a 
hypnotic in the treatment of the insomnia due to melancholia and 
acute mania. 

CHLORETONE. 

Under the name chloretone a substance, which is trichlor-tertiary- 
butyl-alcohol, or acetone chloroform, is often used as a hypnotic and 
nervous sedative closely allied in its uses to chloral, yet different in 
the important particulars that it does not depress the heart or 
respiration unless given in excessive quantities, and does not irritate 
the stomach, but acts as a sedative to this organ. For this reason 
it can be used with advantage in vomiting due to irritation. Given 
in the dose of 5 to 10 grains (0.3-0.65) before etherization, it will often 
prevent after-vomiting, and if vomiting has already begun, is a valu- 
able agent for its relief. When used to prevent ether vomiting, it 
should be given in powder one hour before the ether is used. It is a 
valuable remedy to prevent and relieve seasickness, in doses of 3 to 
5 grains (0.2-0.3) three times a day. Chloretone is an efficient palli- 
ative in tetanus, given by the rectum in the dose of 60 grains (4.0) 



198 DRUGS 

dissolved in warm olive oil, and repeated as often as is needed to 
control spasm. 

The author has also found it of value in relieving the pain of gastric 
ulcer and of gastralgia. As it is both anesthetic and antiseptic, it can 
be employed as an application to burns, scalds and lacerations in 10 
per cent, ointment, and local anesthesia may be produced by the 
subcutaneous injection of it in a 1 per cent, solution of alcohol 15 per 
cent, and water 84 per cent. It may be dissolved in oil of cloves and 
applied on a cotton pledget with advantage in cases of toothache. It 
may also be used to benumb a painful dental nerve by mixing equal 
parts of ether and chloretone and applying this in the cavity. Pow- 
dered chloretone mixed with equal parts of powdered boric acid and 
dusted over painful ulcers, burns, and lacerations or wounds acts as an 
efficient antiseptic dressing, but it may increase the burning at first. 
Chloretone and antipyrine may be given in capsule in the dose of 3 to 
6 grains (0.2-0.4) each and used in restlessness and neuralgia pain. 
The mixture of these substances results in liquefaction, but this does 
not interfere with their therapeutic efficacy. 

Chloretone is efficient in doses of from 5 to 20 grains (0.3-1.3), 
and is best given in 5-grain capsules or in pills of about 3 grains (0.2) 
each. Large doses often cause headache as the effects wear off. 

CHLORINATED LIME. 

(See Calx Chlokinata.) 

CHLORODYNE. 

Chlorodyne is a preparation used largely for the treatment of 
serous diarrhea or cramps in the abdomen. Its constitution varies 
considerably, but the formula most commonly employed is as follows : 

1$ — Morphinae hydro chloridi gr. viij (0.5) 

Aquae destillatae f 5ss (2.0) 

Heat together, and as soon as the morphine is dissolved and the liquid cooled, add: 

Acidi hydrochlorici diluti f 5ss (2.0) 

Chloroformi f 5iss (6.0) 

Tincturae cannabis f 5J (4.0) 

Acidi hydrocyanici diluti ITflxij (0.8) 

Alcoholis f5ss(16.0) 

Olei menthae piperitae lUxij (0.8) 

Oleoresinae capsici Tflj (0.05). — M. 

S. — Five to 15 minims (0.3-1.0) for an adult, in water, every two hours for three 
doses. More than this quantity is dangerous. 

Under the name of Mistura Chloroformi et Cannabis Indices Com- 
posita the N. F. contains a recipe, each fluidram (4 cc) of which 
represents about 7 minims (0.45 cc) of chloroform, 10 minims (0.6) of 
tincture of cannabis, 2 minims (0.12) of tincture of capsicum, and 
y grain (0.009) of morphine sulphate. 

A formula closely allied to this is used in tablet form. 



CHLOROFORM 199 

CHLOROFORM. 1 

Chloroform (Chhroformum, U. S. and B. P.) was discovered by 
Guthrie (1831), of Sackett's Harbor, New York, and was first used 
medicinally (1847) by Simpson, of Edinburgh. It is a clear liquid 
consisting of 99 to 99.4 per cent., by weight, of absolute chloroform 
(CHC1 3 = 118.45) and 0.6 to 1 per cent, of alcohol. It should be kept 
in dark amber-colored, glass-stoppered bottles, in a cool and dark 
place. Chloroform has an exceedingly hot, burning, sweetish taste, 
has a rather agreeable odor, and is very volatile. Its chemical name 
is trichlormethane. It is soluble in 200 parts of water. 

There are two kinds of chloroform— the purified (Chhroformum, 
U. S.) and the commercial chloroform {Chhroformum Venale). 

If exposed to the light for any length of time, chloroform develops 
carbonyl chloride, hydrochloric acid, and chlorine, which render it 
unfit for use. If the acid is present, it will turn blue litmus red; and 
if chlorine is present, it will form a white precipitate with nitrate of 
silver. Such impure chloroform may be rectified by shaking it with 
slaked lime and filtering until the irritating products are gotten rid 
of. If impure because of improper methods of manufacture, an oily 
odor will be left on the hand after evaporation takes place. We 
find, therefore, that chloroform suitable for anesthesia should be 
transparent and colorless, neutral to test-paper, non-irritating when 
inhaled, and should evaporate completely when placed on a watch- 
glass, leaving no residue or odor. It should have a specific gravity 
not below 1.476, should form no precipitate with AgN0 3 , should 
not become brown when heated with caustic potash, and only very 
faintly brown, if at all, when shaken with concentrated H2SO4. 

Chloroform vapor in the presence of a gas-flame undergoes certain 
changes which result in the development of noxious and irritating 
fumes, consisting principally of hydrochloric acid and chlorine, which 
produce laryngeal and bronchial irritation. The deleterious effects 
of these fumes can, however, be neutralized if a cloth or towel wet 
with aqua ammonia be hung up in the operating-room. 

Physiological Action.— Locally applied to the skin, chloroform may 
produce some tingling and burning even if evaporation be not inter- 
fered with. If confined under a watch-glass on the skin, it will cause 
a blister and act as a counterirritant. 

When inhaled, chloroform produces a sensation of warmth in the 
mouth and throat, a feeling of relaxation, and, finally, unconscious- 
ness. The respirations are at first full and deep, but soon become 
rapid and shallow. The pulse may be somewhat stronger and 
fuller for short interval, probably because of mental excitement, but 
soon fails in strength and becomes more rapid. The irritation pro- 
duced in the air-passages by its inhalation is slight and no primary 

1 The student should read the article on Ether in conjunction with this article. 



200 



DRUGS 



arrest of respiration ensues, as is generally seen after ether is first 
given. The pupils are at first slightly dilated, but are contracted 
during anesthesia. If the pupils dilate during the use of chloroform 



Fig. 25. 



Fig. 26. 





Fig. 27. 




Fig. 25. — A, chloroform depresses the vasomotor center; B, chloroform dilates the 
heart and depresses it; C, chloroform depresses the respiratory center. 

Fig. 26. — A, chloroform produces anesthesia by depressing the perceptive centers 
in the brain and later depresses the (B) intellectual centers, and finally depresses the 
(C) motor centers. 

Fig. 27. — D, depresses the sensory paths in the spinal cord; E, finally depresses 
motor tracts in the cord. 



after the contraction just named, danger is imminent and death may 
suddenly occur. In some persons the first effects of chloroform are 
violent struggles, and there is danger in trying to overcome these 
struggles by pushing the drug very rapidly. Not only is this a 



CHLOROFORM 201 

well-recognized fact depending upon clinical observations, but Sher- 
rington and Sowton have proved experimentally that the heart is 
peculiarly susceptible to the depressant effects of chloroform when it 
is simultaneously exposed to an abnormal quantity of C0 2 in the 
blood. Further than this Brodie has shown that the rate of absorp- 
tion of chloroform is greater during the second minute of its inhala- 
tion than at any other time and that the volume expired is less 
during this period. Struggling is particularly apt to be met with 
in athletes and drunkards. Total muscular relaxation should never 
be produced by the drug. 

x 



B 



y 



Fig. 28. — Diagram to show effect of moderate closes of chloroform on the sensory 
paths of the spinal cord. From the area B, the pia mater is removed, so preventing 
the chloroform from reaching it. If the nerve-trunks (x or z) are irritated, no reflex 
takes place because the sensory parts are obtunded, but if nerve y is irritated, reflexes 
occur all through the cord because that sensory part is not obtunded, and the motor 
paths have not been touched. 

Nekvous System.— Chloroform first affects the sensory part of the 
brain, then the sensory part of the spinal cord, then the motor tract of 
the cord, then the sensory paths of the medulla oblongata, and finally 
the motor portion of the medulla, thereby producing death from 
failure of the vasomotor center and of the respiratory center, unless, 
as rarely occurs, the heart has already succumbed to the drug. The 
effect on the sensory portion of the cord may be proved by the 
above experiment explained in diagram. 

On the sensory and motor nerves, when locally applied, it acts as 
an irritant and anesthetic. Upon these nerve-trunks, when taken by 
inhalation, it has little or no effect. 

Meyer and Overton believe that chloroform acts as an anesthetic 
by solution of the lipoid or fatty constituents of the brain cells. The 
solution is intracellular and the fat is not removed from the cell. 

Blood.— Upon the blood in the body chloroform has little or no 
effect when it is inhaled. Shaken with chloroform in a bowl, the 
blood becomes scarlet in hue. 

Buckmaster and Gardner have shown that anesthesia develops in 
animals when the quantity of chloroform is from 14 to 27 milligrams 
to 100 grams of blood, and that death ensues when the proportion is 
40 milligrams to 100 of blood. These investigators also found that 
the greater part of the absorbed chloroform is held by the corpuscles, 
the plasma holding very little. Harcourt believes that the quantity 
absorbed is about one-third of that inhaled. 



202 DRUGS 

Circulation and Respiration.— The effects of chloroform upon 
these vital functions have been for many years a subject of hot dis- 
pute between surgeons and pharmacologists. On the one hand is 
the school originally led by Syme, of Edinburgh, which has asserted 
that death or danger from chloroform lies in failure of the respiration 
and that this was the function to be watched while chloroform was 
being used; on the other hand, the so-called London school asserted 
that death arises from cardiac failure and that the pulse is the thing 
to be watched during the use of chloroform. The number of clinical 
and laboratory researches which have been carried out to determine 
which of these opinions is correct has been very great, both in England 
and in America, but it has only been within the last thirty years 
that the most competent studies have been undertaken, of which 
the best known is the series made through the munificence of His 
Highness the Nizam of Hyderabad in India, and known as the 
"Reports of the Hyderabad Chloroform Commissions Nos. 1 and 
2." The conclusions of the first commission having been criticised 
adversely because it asserted that the cause of death was respiratory 
failure, a second commission was formed, and, under a grant of $5000 
from the Nizam, Sir Lauder Brunton, of London, was sent out to 
direct the second investigation. Although a teacher of the theory 
that death from chlorform is due to cardiac failure, this investigator 
returned to England converted to the idea that the cause of most 
of the fatal accidents under this drug is respiratory failure, and the 
conclusions of Commission No. 2 were also criticised by numerous 
clinicians and pharmacologists in England and America. About this 
time H. C. Wood and the author published a paper in which they 
expressed their belief in the depressing effects produced by chloro- 
form upon the heart; and MacWilliams, of Glasgow, proved by 
experiment that chloroform causes cardiac dilatation and enfeeble- 
ment. Shortly afterward the author of this book was requested by 
the government of His Highness the Nizam, through Colonel Edward 
Lawrie, the Residency Surgeon, to carry out a series of studies 1 
designed if possible to reconcile the contradictory results reached by 
the Hyderabad Commissions and other investigators, and simul- 
taneously Gaskell and Shore in Cambridge University, England, 
were asked to do likewise. The result has been to confirm in every 
way the results of all previous studies in one respect— namely, that 
the primary action of chloroform on the vital function of circulation 
is greatly to depress the vasomotor system, thereby causing an extra- 
ordinary fall of blood-pressure. Gaskell and Shore, to be sure, assert 
that anesthesia can be produced by chloroform without causing this 
fall, but the author has never been able to do so (Fig. 29). They 
also believe that the fall is chiefly a result of cardiac failure. From 
this view the author dissents, because their experiments upon which 

1 Therapeutic Gazette, October, 1893. 



CHLOROFORM 



203 



these assertions are based were too complex to give practical results; 
and second, because his own studies and those of others show the 
vasomotor system to be depressed. There is of course some cardiac 
enfeeblement and dilatation, which add to the fall of pressure. 

As with other discussions in medicine, the truth of the question as 
to whether chloroform causes death by respiratory failure or cardiac 
failure lies, as it were, half-way between the two antagonistic opinions; 
and, further than this, the somewhat startling statement may be 
made that it is not directly due, in the majority of cases, to either 
of these causes. On the contrary, the cause of death from chloroform 
is usually vasomotor depression whereby the arterioles allow the 
blood to pass too freely into the great bloodvessel areas which exist 



1 M I I I 1 I I I M I I I 1 II 



i 1 1 nn i 1 1 mi n i i i i i i n u U 1 1 i i i it i 1 1 i i i 1 1 1 i i i 




M I M 11 I I I I 11 I I I I 1 I I M I I I I I 



wvvvwwwvwvv 



I 1 I 1 I I I I I I I 1 I I I I I I I I I I I I H I I I I I I HI i I I I 




Fig. 29. — Tracings showing the pulse and blood-pressure depressed by chloroform. 
Note the fall of blood-pressure which begins in the upper tracing and becomes marked 
in the second tracing. Also notice the weak pulse shown in the third tracing, illus- 
trating the final depressant effect of the drug on the heart. The respiration ceased 
at X, but the heart continued to beat. The blood-pressure failed first, then the pulse, 
then the respiration, and last of all the heart stopped. (Reduced from natural size.) 



in the capillaries and veins, and as a result the man is suddenly bled 
into his own vessels as effectually as if into bowl. When it is remem- 
bered that the capillary network of the body will, with the relaxed 
veins, hold many times the normal quantity of blood, and when it is 
remembered that we can inject salt solutions into the vessels to the 
extent of several times the normal quantity of blood without raising 
the blood-pressure, it at once becomes evident that the complete 
vascular relaxation caused by chloroform results in failure of all the 
vital functions, not because the drug has paralyzed the heart or 
respiratory center, but because these parts are deprived of blood by 
its stagnation in the widely dilated capillaries and abdominal veins. 
Studies by Leonard Hill on The Physiology and Pathology of the 



204 DRUGS 

Cerebral Circulation show that this is the case, for he asserts that 
when the blood is no longer flowing to the respiratory centers the 
heart is still beating, because its coronary arteries, being lower 
down, are more easily supplied by the small bloodstream received 
by the heart from the veins. These studies are proved by the 
experiments of the author and his assistant, Dr. Thornton, 1 by every 
tracing of the Hyderabad Commissions, and all other tracings we 
have ever seen. Lockhart Mummery has also shown that if a 
dog is beheaded and pithed, and life maintained by artificial respi- 
ration, that it is impossible to stop the heart with chloroform given 
in an ordinary dose. Even when the air supplied to the lungs was 
completely saturated with heated chloroform so that the heart was 
stopped, it could always be revived, showing that it was not truly 
poisoned or destroyed in function by this drug. We may conclude, 
therefore, that while chloroform without doubt acts as a powerful 
depressant poison to the respiratory center and the heart in the same 
manner as it paralyzes all living protoplasm when applied in excess, 
than when properly given by inhalation it produces a death equivalent 
to that resulting from hemorrhage, which is a failure of the respira- 
tion no so much from a direct depression of the respiratory center 
as from its deprivation of blood; and while the tendency of the drug 
is to depress and dilate the heart, just as it dilates the vessels of which 
the heart is merely a highly specialized part, the failure in the pulse is 
due to vasomotor palsy, the patient becoming pulseless because the 
heart has no blood to pump. 

Let us see what evidence supports this view: First, we have the 
laboratory tracings of many independent investigators extending over 
many years and made in all parts of the world, all of which show a fall 
of blood-pressure. Am ong these may be named Bowditch and Minot, 
of Boston; Coats, H. C. Wood, Gaskell and Shore, the Hyderabad 
Chloroform Commissions; the studies of Wood and the author in 
1889 and 1890, and of the author and Thornton in 1892 and 1893. 
They are confirmed by Hill, who has seen the abdominal vessels 
engorged with blood under chloroform, the medulla almost bloodless, 
and the heart still pumping, though respiration had ceased. They 
are confirmed by the author's own experiments, in which he proved 
that even after the respiration had stopped and the carotid was 
empty, the dog apparently dead, it could be resuscitated by visceral 
compression and artificial respiration, and by inversion, whereby the 
blood left the dilated abdominal veins for the heart and brain. Again, 
if a needle was inserted through the chest-wall, the heart was found 
to be beating, for the needle moved to and fro; and finally if the 
chest was opened the heart could still be found beating feebly— 
dilated, it is true, but beating. 

So much for the laboratory evidence. What have we in clinical 

1 Therapeutic Gazette, October, 1893. 



CHLOROFORM 205 

evidence? Equally positive proofs of vasomotor palsy, and none 
of death being purely cardiac or respiratory. For years Chisolm, of 
Baltimore, and later Howard Kelly and a large number of others 
used inversion with compression of the floating ribs in artificial 
respiration, which forced the blood into the chest and saved life 
again and again. For years the literature of medicine has teemed 
with reports of death from chloroform while the patient was sitting 
up or half recumbent, because the blood-paths being dilated, this 
posture favored anemia of the vital centers. Again, it has been 
proved that one of the best vasomotor stimulants— belladonna or 
atropine— given before the chloroform is used increases the safety 
of the patient, and that compression of the limbs by bandages does 
likewise. Recent studies by means of the sphygmomanometer on 
human beings have also shown a marked fall of blood-pressure when 
chloroform is inhaled even in moderate amount. Finally, Hill has 
shown that abdominal compression also aids resuscitation by forcing 
the blood to the heart. On the contrary, saline transfusion, which 
would seem to be indicated, is useless, because the dilated blood- 
paths will receive the saline for a long time before they will overflow 
toward the heart, for as fast as the fluid flows in they dilate. 

The author, therefore, believes that while chloroform in its general 
depressing power depresses all vital functions, it is the question of 
blood-pressure which is most important in the healthy individual, 
although the heart may fail if it be damaged by disease before the 
drug is used. Embly, too, has shown that when anesthesia is first 
induced the vagus centers in the medulla are irritated and may 
arrest the heart temporarily, an arrest which, combined with a 
sharp fall of pressure, may render the arrest permanent. Therefore, 
in the use of chloroform, we should always keep the head low, pre- 
cede its use by atropine hypodermically, bandage the limbs if the 
case is feeble or already bloodless, and, if necessary, place com- 
presses on the belly and press them deeply into the abdomen if 
failure of the circulation develops. 

The primary action of the chloroform is to depress the blood-press- 
ure chiefly by its vasomotor effect, secondly by its cardiac effect, and 
finally, while the drug does exercise a depressant effect on the respi- 
ratory center, the failure of this center is chiefly due to anemia. As 
however, an intact respiratory center means regular breathing, we 
watch this function to determine the dose of chloroform actually 
inhaled, and because any variation in this function, as shown in 
irregular breathing, means that the chloroform is disordering arterial 
tension. Death from chloroform in a healthy organism, then, is 
usually a vasomotor death, for an intact arterial system is as import- 
ant to vital function as an intact cardiac apparatus. 

Temperature.— Chloroform when taken by inhalation distinctly 
lowers the body temperature, probably by aiding in the dissipation of 
heat and by its action on the nervous mechanism of heat production. 



206 DRUGS 

Elimination takes place by the lungs and by the kidneys, and goes 
on very rapidly, owing to the great volatility of the drug. (See 
"Effects on Nervous System.") 

If large amounts are eliminated by the kidneys, these organisms 
are apt to become irritated and inflamed. 

Antiseptic Power.— Chloroform, when it is added to organic fluids, 
prevents all changes which depend upon the growth of microorgan- 
isms. 

Therapeutics.— The first and most important use of chloroform is 
as an anesthetic, and at this point we come to a question which has 
been for many years a matter of contention between different sections 
of the medical profession— namely, as to whether its use is dangerous. 
In the Southern and Western parts of the United States chloroform is 
nearly always used, but in the Eastern and Northern portions it is 
rarely employed. Southerners certainly seem to take chloroform 
better than Northerners or those living on the Atlantic coast. It is 
impossible to go into a general discussion of this question here; suffice 
it to state that even the most enthusiastic supporters of the use of 
chloroform confess that it is a more dangerous drug than ether if care- 
lessly used, and, while the advantages of chloroform are many, this one 
great disadvantage overshadows them all. 1 The advantages are— its 
more agreeable odor and the fact that it does not irritate the air- 
passages, owing to the small amount necessary to cause anesthesia; 
the fact that its use is less apt to be followed by nausea and vomiting; 
the rapidity of its action; and the small bulk which has to be carried 
by the surgeon. Its disadvantage is— the possibility of its killing the 
patient. 

We come, then, to the all-important questions: 

1. Is chloroform a safe anesthetic? 

2. Are we to watch the pulse or respiration during the use of the 
drug, and what are the signs in the respiratory function indicative of 
danger to the patient? 

3. What is the true cause of death from chloroform? 

4. Is death from chloroform possible when it is properly admin- 
istered? 

5. Under what circumstances is the surgeon to use chloroform in 
preference to the less dangerous anesthetic, ether? 

6. What is the best way of administering chloroform? 

To the first question the answer is, Yes for the majority of cases, 
provided it is given by one who is skilled in its use, and not only knows 
how to give it, but also how to detect signs of danger. It is not so 
safe as ether at any time, other things being equal, and never safe in 
the hands of a tyro. 

To the second question the answer is, Watch the respiration, because 

1 The mortality based upon many tens of thousands of cases in which chloroform 
has been used is about 1 in 2039 (Gurlt) ; or according to the combined statistics of 
Julliard and Ormsby, in 676,767 administrations there were 214 deaths — 1 in 3162. 



CHLOROFORM 207 

as soon as enough chloroform is used to endanger the circulation the 
respiration will show signs of abnormality either in depth, or shal- 
lowness, or irregularity. In other words, the very effect of the drug 
may be to cause such deep and rapid respirations that an excessive 
quantity of the drug is taken into the lungs and continues to be 
absorbed even after the inhaler is withdrawn. 

As there is always a fall of blood-pressure under chloroform, it is 
difficult to feel the radial or temporal pulse, and the respiratory center 
recognizes the degree of arterial depression which its sister vasomotor 
center has permttted by finding that its blood-supply is insufficient. 
As respiration fails first, it should be watched first. It is only by 
watching the respiration that we can tell how much chloroform the 
patient is getting. We do not watch this function for danger alone, 
but to determine the dose. 

Everyone is agreed that the patient taking chloroform should have 
plenty of fresh air, and in India, to all intents and purposes, patients 
are operated on in the open air, at least as compared to the closed 
rooms necessary in America and Europe. This free supply of air is 
important whether death is believed to be imminent from cardiac or 
respiratory failure; but this supply of air matters little to the patient if 
he does not breathe freely, nor does the quantity of chloroform amount 
to aught if it is not drawn into the lungs. The dose of chloroform is 
not the amount on the inhaler, but the amount taken into the lungs, 
and, finally, the amount absorbed by the bloodvessels. The rapidity 
and depth of respiratory movements is, therefore, as Lawrie asserts, 
the key to the situation. We withdraw chloroform, as Lawrie says, 
whenever respiration becomes disturbed in rhythm or when struggling 
disturbs it, because it is the first indication that the drug's action is 
uncertain, and because there is no means of determining the dose 
which is absorbed. While watching the respiration will not warn us 
of a sudden cardiac arrest in fatty heart plus chloroform depression, 
neither will the pulse give us such warning; and I am confident that 
the statement of the Hyderabad Commission, that the respiration 
should be watched, is correct, for I believe, from a series of observa- 
tions that gradual cardiac failure never occurs without producing 
respiratory changes from the very first. In other words, I do not 
believe that in a healthy heart chloroform can cause serious disorder 
without, as a result of beginning disorder, disturbing respiration ; and, 
second, that in the healthy heart a quantity of chloroform sufficient 
to disorder it will by its direct action disorder the respiration. If, as 
an extra precaution, one assistant watches the pulse while another 
watches the respiration, very well, for though the respiration is the 
more important function to watch, the person watching the pulse 
might discover an irregularity which the anesthetizer may not see 
reproduced in the respiratory action; but as divided attention gener- 
ally means a slighting of both objects in view, Lawrie is right in insist- 
ing on the pulse being ignored. 



208 DRUGS 

The answer to Question 3 is that death is always due in the healthy 
person to vasomotor failure accompanied by respiratory depression, 
the vascular relaxation being severe enough to cause death even if 
artificial respiration is used skilfully. 

The answer to Question 4 is, Yes. The physician having a case of 
heart disease requiring surgical interference should always advise the 
patient of the danger of an anesthetic, and he should remember, 
whether it is wise to tell the patient or not, that anesthesia always 
means an approach to death even in the healthiest of men. In the 
even of a death under chloroform the physician is blameless if he has 
taken suitable preliminary precautions and given the chloroform 
properly. 

To Question 5 we have several answers to make: 

1 . Chloroform may be used in hot climates (when ether is inapplic- 
able), where a free circulation of air increases the safety of the patient. 

2. Chloroform may be used whenever a large number of persons are 
to be rapidly anesthetized, so that the surgeon may pass on to others 
and save a majority of lives, even if the drug endanger a few, as on 
the battlefield, where only a small bulk of anesthetics can be carried. 

3. The employment of chloroform is indicated in cases of B right's 
disease requiring the surgeon's attention, owing to the fact that anes- 
thesia may be obtained with such a small quantity of the drug that 
the kidneys are not irritated, whereas ether, because of the large 
quantities necessarily used, would irritate these organs. Quantity 
for quantity, ether is, however, the less irritant of the two. 

4. In cases of aneurism or atheroma of the bloodvessels, where 
the shock of an operation without anesthesia would be a greater 
danger than the use of an anesthetic, chloroform is to be employed, 
since the struggles caused by ether and the stimulating effect which 
it has on the circulation and blood-pressure might cause vascular 
rupture. 

5. In children or adults who already have bronchitis, or who are 
known to bear ether badly, or, in other words, have an idiosyncrasy 
to that drug, chloroform may be employed. 

Other indications for the use of chloroform in preference to ether are 
in the performance of brain surgery, where ether is apt to produce 
meningeal congestion by vomiting. In performing tracheotomy, if 
the case is urgent and the ether produces respiratory irritation, chloro- 
form may be used with advantage. 

Chloroform inhalations have been recommended in excessive chorea 
and in puerperal convulsions, and are of great service in the reduction 
of hernia, owing to the muscular relaxation produced. 

Sometimes a few whiffs will put a nervous patient to sleep, but its 
use as a hypnotic is very dangerous, as it may produce a habit, and 
the habit is apt to end fatally, but I have under my care a feeble 
old woman of nearly seventy years, who used for years about half 
an ounce every night, by inhalation, to allay cough. 



CHLOROFORM 209 

Parturient women seem able to take chloroform with more safety 
than other women. There are four important factors in lessening the 
danger of chloroform in this class of cases: 1st. Less chloroform is 
given than is usual in surgical operations. 2d. The pregnancy may 
produce immunity by reason of the slight cardiac hypertrophy pro- 
duced at this time. 3d. The absence of fright, for the woman wel- 
comes the anesthetic. 4th. The frequently recurring pains of labor so 
stimulate the vasomotor center that the dominant action of chloro- 
form—namely, vasomotor depression— is combated. 

In severe whooping-cough a few drops of chloroform may be poured 
on the back of the hand of the attendant and the hand held before 
the child's face. While the child may at first dislike the odor of the 
drug, the relief given soon teaches the patient its value, and he will 
ask for it when he feels the attack coming on. If the attack is pro- 
longed and violent, this treatment must be used with caution, owing 
to the strained condition of the heart-muscle, which may be still 
further depressed by the frequent use of the drug. The drug should 
not be poured on a cloth, but on the nurse's hand. In this way too 
much of it cannot be given to the patient at one time. 

Administration.— When chloroform is given it should be poured 
drop by drop upon an Esmarch inhaler, or upon a folded napkin or 
towel, in which case the cloth should then be held about three to six 
inches from the mouth and nose, so that the vapor may be thoroughly 
mixed with air in the proportion of 2 per cent, of vapor to 98 of air; 
0.5 per cent, does not cause unconsciousness and 5 per cent, is danger- 
ous. The British Special Chloroform Committee (1910) points out 
that in grave disease and feebleness less than 2 per cent, should be 
used to avoid danger, and in persons of this type even so low a per- 
centage as 0.5 will prove efficient. The percentage to be used is that 
which is adequate and does not exceed 2 per cent. Two per cent, 
should not be exceeded at any time during its use. The character 
and form of the material used to cover the inhaler or to hold the 
chloroform is of greater importance than would appear at first sight. 
Thus, a single layer of flannel, although it holds less chloroform than 
will several layers, nevertheless may provide the patient with a 
greater amount of chloroform, because under these conditions the air 
is drawn through the meshes of the flannel instead of over its surface, 
as it is when the several thicknesses prevent the through-and-through 
passage of air. Again, the degree to which chloroform spreads when 
poured on different fabrics is of some interest. It spreads more 
rapidly over loosely woven cloths than over tightly woven ones, and 
so exposes a greater surface for vaporization and permits a greater 
dose of chloroform per inhalation not only by this means, but by the 
fact that air is readily drawn through its meshes. 

The anesthetist should never permit himself to hurry the patient 
under the effect of the drug nor should he permit any preliminary 
measures or the primary incision to be made until the patient is well 

14 



210 



DRUGS 



under. Many deaths have resulted from carelessness in these par- 
ticulars. 

The administration must be gradual, as "pushing" the anesthetic 
is dangerous. The best way to use the drug is by means of a " chloro- 
form dropper ampoule," which is so constructed that it falls upon the 
inhaler drop by drop. 

The safest method of administration is by Esmarch's or Lawrie's 
inhaler, because these provide a free circulation of air and the atten- 
tion of the anesthetizer is not distracted from the respiratory move- 
ment by the manipulation of complicated apparatus. 

The dangers of chloroform seem to be considerably decreased by 
the simultaneous administration of oxygen gas with the anesthetic 
vapor. (For the best method of using oxygen and chloroform 
together see Oxygen, Important.) 




Fig. 30. — Esmarch' 



inhaler and chloroform bottle. The inhaler consists of a wire 
frame covered by a piece of thin flannel. 



The author largely agrees with Lawrie's published conclusions, 
which are as follows with slight modifications : 

1. The chloroform should be given on absorbent cotton, stitched 
in an open cone or cap. 

2. To insure regular breathing, the patient, lying down, with the 
clothing loose about the neck, heart, and abdomen, should be made to 
blow into the cone, held at a short distance from the face. The right 
distance throughout the inhalation is the nearest which does not cause 
struggling or choking or holding of the breath. 

3. The administrator's sole object while producing anesthesia is 
to keep the breathing regular. As long as the breathing is regular 
and the patient is not compelled to gasp in chloroform at an abnormal 
rate, there is comparatively little danger. 



CHLOROFORM 211 

4. Irregularity of the breathing is generally caused by insufficient 
air, which causes the patient to struggle or choke or hold his breath. 
There is little or no tendency to either of these untoward effects if 
sufficient air is given with the chloroform. If they do occur, the cap 
must be removed and the patient allowed to take a breath of fresh 
air before the administration is proceeded with. 

5. Full anesthesia is estimated by insensitiveness of the cornea. 
It is also indicated by stertorous breathing or by relaxation of the 
muscles. Directly the cornea becomes insensitive or the breathing 
becomes stertorous inhalation should be stopped. The breathing 
may become stertorous while the cornea is still sensitive. The rule to 
stop the inhalation should, notwithstanding, be rigidly enforced, and 
it will be found that the cornea always becomes insensitive within a 
few seconds afterward. 




Fig. 31. — Lawrie's collapsible inhaler, made of four small pieces of bamboo covered 
with muslin. The chloroform may be dropped on the sides of the inhaler. 

Above all, it is necessary to remember the fact that a person having 
taken chloroform twenty times before does not show he is not in 
danger on taking it the twenty-first time; and it is also to be borne 
in mind that many of the sudden deaths from chloroform have 
occurred during the first stage of the inhalation of the drug before 
consciousness has been lost, and, therefore, when an accident was 
least expected. 

In operations about the mouth chloroform may be employed by 
passing a soft catheter through the nose and then by means of a hand- 
bulb attached to a small wash-bottle containing chloroform, or by 
means of a Junker inhaler, introducing into the post-nasal spaces 
chloroform vapor mixed with air. 



212 



DRUGS 



Some of the evil effects of chloroform can be avoided if the physician 
in charge of the case will not only attend to the state of the stomach 
and bowels, but the cardiovascular state as well. Given a patient 
who is suffering from arterial spasm and fibrosis, there can be no doubt 
that he will pass through chloroformization far better if for several 
days before the use of the drug he have rest in bed and possibly a 
course of one of the nitrites. So too, in cases in which hypotension 
is present, a course of cardiac tonics and the use of strychnine hypo- 
dermically to combat vascular relaxation is advantageous. 

It is often a good plan to give atropine hypodermically before 
using chloroform, in order to avoid relaxation of the splanchnic vessels, 
but the preliminary use of morphine is usually unwise. The danger 
of an accident is greatly increased if the patient is placed in the 
Trendelenburg posture. 

Individuals who are robust and strong and who struggle violently 
are in greater danger from the use of chloroform than the sickly and 

weak, probably because the strug- 
gles cause deep inhalation of the 
drug, exhaust the vasomotor sys- 
tem, strain the heart and tend to 
dilate its walls. 

The question has arisen a num- 
ber of times whether it is possible to 
chloroform a person who is asleep 
without his being awakened. This 
has been decided by numerous tests 
to be possible, particularly if the 
sleep be heavy. 

Before closing the consideration 
of the use of chloroform for anes- 
thetic purposes mention should be 
made of the so-called anesthetic 
mixtures. Of these the A. C. E. 
is the best known. It consists of a 
mixture of 1 part of alcohol (sp. gr. 0.838), 2 parts of chloroform (sp. 
gr. 1.497), and 3 parts of ether (sp. gr. 0.735). Billroth's A. C. E. 
mixture is composed of chloroform 3 parts, and ether and alcohol 1 part 
each. The Vienna mixture consists of 1 part of chloroform and 5 of 
ether, and the so-called methylene mixture in 30 per cent, methylic 
alcohol, and 70 per cent, chloroform. The object of all these mixtures 
is evident— namely, to get the anesthetic effect of the ether and 
chloroform without the cardiac and respiratory effect of either, and 
the alcohol when added is to act as a stimulant. As the volatility 
of each ingredient varies, the mixture is futile, for the ether evaporates 
first, and the chloroform next, and the alcohol last. The A. C. E. 
is popular in England, but not in the United States. 

A brief anesthesia for dressing painful wounds and burns may be 




Fig. 32. — Krohne and Seseman's 
modification of Lawrie's inhaler, with 
feather respiration-indicator attached. 
The inner lining is of white felt, the 
outer case is of leather. The chloro- 
form may be poured on the felt through 
a small hole in the leather on the top 
of inhaler. 



CHLOROFORM 213 

induced by the following mixture largely employed in the great war : 
Ethyl chloride 5 cc, chloroform 1 cc, ether 24 cc. This quantity is 
placed on flannel and put over the patient's mouth and nose with a 
piece of dry flannel over it, and this again is covered by oil silk in 
which is a hole for the nose. Anesthesia starts with the second 
breath and lasts for about ten minutes. 

Chloroform, when taken internally by the mouth, causes a sensa- 
tion of warmth in the stomach and a hot, burning taste about the lips 
and buccal mucous membrane. In overdose it has produced death 
when taken in this manner. Comparatively rarely used in internal 
medicine, chloroform in the form of the spirit of chloroform (Spiritus 
Chloroformi, U. S.) or water of chloroform (Aqua Chloroformi, U. S.) 
is useful in cough mixtures, which are given to persons having an irri- 
tative cough, and in cases where, through nervousness or other cause, 
tickling in the throat or bronchial tubes keeps the patient continually 
in a state of unrest. (See Bronchitis.) 

In gastric or intestinal flatulence 3 or 6 minims (0.15-0.3) of pure 
chloroform, or 30 to 60 minims (2.0-4.0) of the spirit of chloroform, 
will often give relief. The following prescription is useful in all forms 
of abdominal pain and is harmless in ordinary dose : 

]$ — Spiritus chloroformi . . f §ss (16.0) 

Spiritus camphorse f 3ij (8-0) 

Tincturse lavendulse compositse . . q. s. ad f5iij (90.0). — M. 

S. — Dessertspoonful (8.0) in water every twenty minutes for four doses. 

In the treatment of serous diarrhea the spirit of chloroform when 
combined with astringents and opium is most useful, provided that 
the irritating cause is first removed. In renal or hepatic colic a few 
inhalations, not sufficient to disturb consciousness, will not only give 
temporary but sometimes permanent relief by relaxing spasm. Hypo- 
dermic injections of 10 to 15 drops (0.6-1.0) of pure chloroform, 
reaching down to a painful sciatic nerve, have been recommended by 
Bartholow. This is a very painful treatment, and may cause a 
slough. Rubbed on the chest in the form of chloroform liniment, this 
drug will sometimes prevent asthmatic attacks, but chloroform ought 
not to be inhaled, except most carefully, in this affection, because of 
the strained condition of the right side of the heart. 

In dram (4.0) doses chloroform has been used as a remedy for 
tapeworm, but ought never to be so employed. 

When placed in liniments of a stimulating character chloroform is 
a very useful application over muscles affected by soreness and stiff- 
ness, as in lumbago and gout, and chloroform liniment may also be 
used over neuralgic areas for its local anesthetic effect. 

Contraindications.— Chloroform is not to be used in cases of fatty 
heart or dilatation of the heart, in those with a known idiosyncrasy, 
nor in so-called lymphatic persons with overgrowth of lymphoid 
tissue, as, for example, adenoids. In the latter class it is particularly 
apt to cause sudden death. In valvular disease of the heart chloro- 



214 DRUGS 

form may be used with caution, although ether is preferable. Given 
a case of valvular disease that must be subjected to operation, the 
chances are better with an anesthetic, as the pain and mental shock 
are worse for the heart than is the anesthetic. (See Suprarenal 
Gland.) 

Untoward Effects and their Treatment.— Vomiting after the use of 
chloroform develops in about 15 per cent, of cases. Alarming effects 
produced by this drug are far more apt to appear in males than in 
females, the relative proportion being about 6 to 1. Sometimes 
during the administration of chloroform the heart or respiration 
suddenly ceases, and in some cases this change is preceded by a 
peculiar shade or cloud which passes over the face of the patient; but 
death may come suddenly and without warning. If untoward effects 
appear, the anesthetic must be at once withdrawn and artificial 
respiration resorted to. Injections of ether and brandy should be 




Fig. 33. — Showing the attitude in which the head should be held to permit the 
easy passage of air through the glottis. This position raises the epiglottis and lifts 
the soft palate from the tongue. (Martin and Hare's method.) 

given beneath the skin, and the poles of a battery with a rapidly 
interrupted current swept over the body, but not held over the phrenic 
nerve or diaphragm. 1 The patient must be held head downward, so 

1 While few text-books give any specific directions concerning the practical appli- 
cation of the methods which are to be employed in such emergencies, those that do so 
force the physician to a procedure at once dangerous and impractical ; for the directions 
usually given are, to place the positive pole of the battery on the phrenic nerve as 
it crosses the anterior scalene muscle at the root of the neck, the negative pole being 
pressed against the lower margin of the ribs. A rapidly interrupted current is now 
to be used with the purpose of causing contraction of the diaphragm by the direct 
action of the electricity upon the nerve. Even theoretically this is a possible source 
of danger, and practically the writer has proved danger to be ever present under 
such treatment. The cardiac inhibitory nerves run so closely to the phrenic fibers, 
and respond so readily to electrical stimulation, that it is difficult to imagine how they 
can escape stimulation if a current be used of sufficient strength to excite the phrenic 
nerves near by. By practical experiment the writer has proved that inhibition of 
the heart may not only be possibly brought about by this method, but also that it is 
nearly impossible to avoid such an effect if the phrenics are to be reached. 



CHLOROFORM 



215 



that the blood will flow to the brain, as Leonard Hill and the author 
have shown that the chief cause of death is vasomotor relaxation with 
accumulation of the blood in the abdominal vessels. Bandages 
should be applied to the limbs and compression, by means of a bandage 
and large compress, be exercised on the abdominal contents, and active 
artificial respiration practised for a long period of time as the most 
important measures for the patient's relief. External heat should 
be applied. Atropine, strychnine, caffeine, and digitalis may be used 




Fig. 34. — Showing the inversion of the patient as adopted by Kelly, and the method 
of performing artificial respiration simultaneously. The chest is expanded by drawing 
its lower segment toward the operator. 



to stimulate the heart and respiration. Of these, strychnine is the 
most valuable. (See directions under the article on Ether.) Adrenalin 
chloride is contraindicated in that it increases the danger of ventricular 
fibrillation particularly if the anesthesia is light. (See Suprarenal 
Gland.) 

In addition to the movements of artificial respiration, the tip of the 
tongue may be grasped by a pair of forceps and drawn out of the 
mouth and upward from ten to fourteen times a minute, in order to 



216 



DRUGS 



stimulate the diaphragm. (See Asphyxia, Part IV, for detailed 
directions.) In a number of cases patients apparently dead from 
chloroform have been resuscitated by repeated massage of the pre- 
cordium, and even by incising the abdominal wall and massaging the 
heart through the diaphragm. 

The measures adopted for resuscitation should not be stopped for 
at least one hour, as individuals have recovered as long as this after 
an accident from chloroform. 




Ftg. 35. — Same as Fig. 34, except that the floating ribs are compressed to expel 
the air from the chest. 



Ostertag has found that very prolonged inhalations of chloroform 
in the lower animals produce widespread fatty degeneration. 

Caspar, in 1850, and, more recently Guthrie, in England, and Bevan 
and Favill, in America, and an increasing number of other observers 
have published researches in which they found that anesthetics, espe- 
cially chloroform, can produce a destructive effect upon the cells of the 
liver and kidneys, and on the cells of the heart and other muscles, 
resulting in fatty degeneration and necrosis, very similar to the effects 
produced in phosphorus poisoning. These changes are most marked 



CHLOROFORM 217 

in the liver. Further, they are in direct proportion to the amount of 
the anesthetic employed and the length of the anesthesia; and again, 
certain individuals exhibit an idiosyncrasy or susceptibility to this 
effect of chloroform. Of the predisposing causes, they find that child- 
ren are more susceptible than adults; that conditions of lowered 
vitality, such as diabetes, infections, and intoxications, predispose to 
it, and, indeed, any condition which tends to produce exhaustion, as 
do also sclerotic changes in the liver and kidneys. As a result of this 
fatty degeneration of the muscle and liver cells, toxins are produced 
which are ordinarily eliminated, but which in certain cases are 
retained, and these toxins produce a definite chain of symptoms which 
appear in from 10 to 150 hours after the anesthesia, and consist 
in vomiting, retching, delirium, convulsions, coma, Cheyne-Stokes 
respiration, cyanosis, jaundice, and usually death. A certain number 
of mild cases are met with in which a transient jaundice occurs and 
in which recovery takes place. Bevan and Favill consider that the 
hepatic changes are as definite as those found in the pancreas in acute 
pancreatitis, and that, as by-products in this toxemia, but not as the 
essential poisons, are found acetone, diacetic acid, and beta-oxybutyric 
acid in the blood and urine. They assert that the damage to the liver 
may be so great as to cause a total destruction of this organ, and they 
state that this serious and evil late effect of chloroform, which has 
heretofore not been generally recognized, must still further limit the 
use of this powerful and dangerous agent. They believe that diabetes, 
sepsis, starvation, hemorrhage, and fatty degeneration contraindicate 
the use of chloroform, and that the possibility of this condition arising 
also militates against the employment of chloroform in prolonged 
operations, particularly in children. If acetone is found in the urine, 
the use of chloroform is contraindicated. 

When acetonuria is found after the use of chloroform, the patient 
should be treated as if he had diabetic acetonuria. (See Diabetes.) 
Bicarbonate of sodium, given in full doses, may be used as a prophy- 
lactic measure for several days before operation when this complica- 
tion is feared, and large doses are advantageous to combat the condi- 
tion when it is present. Glucose may also be used in doses of J ounce 
(15.0) in water by the stomach after this viscus has been washed 
out with a solution of sodium bicarbonate. A dram in 5 per cent, 
strength is the dose of glucose for a child. If the state is very urgent, 
the glucose may be given intravenously in normal salt solution. (See 
Diabetes.) 

There can be no doubt that the danger of acidosis resulting from the 
use of chloroform is greatly increased by starving the patient before 
the anesthetic is given, and it has been proved that the use of easily 
assimilated or predigested starchy foods shortly before the production 
of anesthesia probably greatly decreases the danger of this grave com- 
plication, just as full amounts of carbohydrate food are indicated in 
cases of diabetes threatened by diabetic coma. 



218 DRUGS 

Local Use and Internal Administration.— The official preparations of 
chloroform are a liniment (Linimentum Chloroformi, U. S. and B. P.), 
a water (Aqua Chloroformi, U. S. and B. P.), dose J to 2 ounces 
(16.0-60.00); a spirit (Spiritus Chloroformi, U. S. and B. P.), the dose 
of which is 20 minims to 1 fluidram (1.3-4.0). The B. P. recognizes, 
besides those given, Tinctura Chloroformi et Morphince Composita, 
dose 5 to 15 minims (0.3-1.0). 

CHROMIUM TRIOXIDE. 

Chromic acid (Chromii Trioxidum, U. S.; Acidum Chromicum, B. P.) 
is not a true acid, but an anhydride, and occurs in the form of brilliant 
red crystals, which are deliquescent and possess a sour, metallic taste. 
The acid should be kept in glass-stoppered bottles. It should never 
be mixed with sweet spirit of nitre, strong alcohol, or glycerin, or any 
organic matter, as under these circumstances an explosion may result. 

Therapeutics.— Chromium trioxide is used solely as a caustic for the 
destruction of growths on the skin or mucous membranes. When a 
limited area is to be destroyed, a small crystal is placed on the part to 
be cauterized ; but if a larger area is to be attacked and severe action 
is required, the liquid resulting from its deliquescence on exposure to 
the air may be employed by means of a glass rod. The surrounding 
tissues should always be protected with lard or adhesive strips. 

J. William White has recorded a death from the application of 
chromium trioxide to a large number of condylomata about the 
buttocks and vulva. Where the drug has been swallowed, the patient 
should be treated for gastro-enteritis, and dilute alkalies and lime- 
water be used, as well as emetics and demulcent drinks. 

If a superficial action is desired, a solution containing 100 grains 
to the ounce (6.6-30.0) of water is sufficient, and for small warts and 
similar growths this solution will be found sufficiently strong. 

Liquor Acidi Chromici, B. P., is composed of 1 part of acid to 3 of 
water. 

CHRYSAROBIN. 

Chrysarobin (Chrysarobinum, U. S. and B. P.) is a neutral principle 
derived from a powder found in the wood of the tree Vouacapoua 
araroba, which was originally used for medicinal purposes in Brazil. 
In the East Indies it is called "Goa powder." Chrysarobin is some- 
times misnamed chrysophanic acid, and is a yellow, tasteless powder, 
soluble in solutions of alkalies, in acids and in ether. 

Therapeutics.— Chrysarobin is given internally in the dose of J- 
grain (0.008) in psoriasis and parasitic diseases of the skin, but more 
commonly is employed externally in the form of the official ointment 
(Urguentum Chrysarobini, U. S. and B. P.) which is too strong for 
direct use, and should be mixed with 4 or 5 parts of benzoated lard 
before application to the skin. Even when so diluted, chrysarobin 



CI MI CI FUG A 219 

may cause great swelling and inflammation of the skin, with desqua- 
mation of the cuticle. Should the surface be broken, the drug may be 
absorbed and cause vomiting. As chrysarobin stains the skin a dark 
brown, it ought not to be used on the face; but should this accident 
occur, the discoloration may be removed by the application of a 
weak solution of chlorinated lime. In psoriasis the following may be 
employed after the patient has taken a bath to soften the scales : 

^ — Chrysarobini 5j (4.0) 

^Etheris, 

Alcoholis aa q. s. ut ft. sol. 

Collodii fgij (60.0).— M. 

S. — Apply with a brush to the part affected. 

CDVHCIFUGA. 

Cimicifuga (U. S.) is derived from Cimicifuga racemosa, otherwise 
known as black cohosh or black snake-root. It contains a resin 
and a volatile oil, upon which its medicinal powers are supposed to 
depend. The fluidextract and tincture should always be freshly pre- 
pared from the fresh crude drug. 

Physiological Action.— In large doses cimicifuga paralyzes the sen- 
sory side of the spinal cord of the lower animals, and in consequence 
lowers reflex activity. It has no effect on the nerves and muscles. 
On the circulation the drug acts by depressing the heart and vasomotor 
system. Death is due to respiratory arrest. In small dose it is a 
feeble cardiac stimulant. When full medicinal doses are given to man 
it nearly always produces frontal headache. Its known physiological 
effects have no direct bearing upon its use in medicine. 

Therapeutics.— Cimicifuga has had an excellent reputation as a 
remedy in chorea, particularly if the patient is otherwise in good health, 
but it should be used w T ith careful attention to the regularity of the 
bowels and often be accompanied by iron. It is also indicated when 
there is, in addition to St. Vitus's dance, a rheumatic tendency. In 
chronic bronchitis it is asserted to be of value, and in rheumatism of 
a subacute or chronic type cimicifuga sometimes gives relief. 

Cimicifuga has been highly praised in the treatment of neuralgia, 
particularly of the ovarian type, and in amenorrhea, subinvolution 
and tenderness of the womb. To women who state that they cannot 
step off a step without paining or hurting the uterus or ovaries cimi- 
cifuga often gives relief. There can be no doubt that it is an active 
uterine stimulant, and it should be used with caution during preg- 
nancy for fear of abortion. There are, however, some practitioners 
who commend its use for the prevention of this accident. By reason 
of this power it may be employed instead of ergot during labor, and 
is said to be better in some cases, because it produces normal, not 
tonic contractions. As a matter of fact, it is little used for this pur- 
pose. In the treatment of headache arising from overstraining of the 
eye cimicifuga is said to be beneficial. 



220 DRUGS 

The drug is official as the extract (Extraction Cimicifuga, U. S.), 
dose 1-5 grains (0.06-0.3), the fluidextract (Fluidextractum Cimi- 
cifugce, U. S., the dose of which is 10 to 30 minims (0.6-2.0) or even 
1 dram (4.0). 

CINCHONA. 

Cinchona, U. S., is the dried bark of Cinchona ledgeriana, Moens, 
Cinchona calisaya, Weddell, Cinchona officinalis, Linne, and of hybrids 
of these with other species of cinchona (Fam. Rubiacece). It should 
yield not less than 5 per cent, of cinchona alkaloids. 

It occurs in quills or curved pieces of variable size, usually 2 or 3, 
sometimes 5 mm. thick; externally, gray, rarely brownish-gray, with 
numerous intersecting transverse and longitudinal fissures, which have 
nearly vertical sides; the outer bark may be absent, the color extern- 
ally being then cinnamon-brown ; inner surface light cinnamon-brown, 
finely striate; fracture of the outer bark short and granular, of the 
inner finely splintery; powder light brown or yellowish-brown; odor 
slight, aromatic; taste bitter and somewhat astringent. Cinchona 
Rubra, U. S., Cinchona? Rubra Cortex, B. P., is the dried bark of 
Cinchona succirubra, Pavon (Fam. Rubiacew), or of its hybrids, 
yielding not less than 5 per cent, of alkaloids of red cinchona when 
assayed by the process given for these alkaloids under Cinchona. 

The alkaloids of tha quinine series derived from these barks are 
quinine or quinina, quinidine or quinidina, and quinicine, which is 
an artificial alkaloid. Of the cinchonine series we have cinchonine, 
cinchonidine, and cinchonicine, which last is also an artificial alkaloid. 
Besides these alkaloids there are present kinic and kino vie acids and 
other inert and useless substances. 

As quinine is the most important of the group, and as its physio- 
logical action is virtually identical with that of the rest, whatever is 
said hereafter in this article refers to quinine unless otherwise stated. 
All the alkaloids of cinchona which have been named are not employed 
as pure alkaloids, but as salts formed by adding sulphuric, hydro- 
chloric, or other acid to increase their solubility. 

Physiological Action.— When quinine is taken in overdose, it causes 
ringing in the ears, dizziness, disorders of taste and smell, disturbance 
of vision in some cases, and fulness in the head. Deafness often 
comes on, and is generally, with the roaring in the ears, the most 
annoying symptom. Headache is not uncommon. (See Untoward 
Effects.) 

Nekvous System.— Upon the cerebrum quinine acts as a stimu- 
lant, and finally as a congestant if given in excessive dose. If poison- 
ous doses are used, intense cerebral congestion ensues, and finally 
unconsciousness comes on. On the spinal cord of the lower animals 
the drug first causes a decrease in reflex action by stimulating, 
Setschenow's reflex inhibitory center, and finally by depressing the 
spinal cord and nerves. The latter changes occur only after poison- 
ous doses. 



CINCHONA 221 

Circulation.— If quinine, even in small amount, be injected into 
the jugular vein of a dog, so that it goes in concentrated form to the 
heart, cardiac paralysis will result. If this does not occur, the drug 
simply decreases pulse-force, pulse-rate, and arterial pressure. When 
given to man in small medicinal doses by the mouth, the drug acts as a 
general stimulant to the entire body, and so tends to support the circu- 
lation, increasing to a slight degree the pulse-rate and blood-pressure. 
If the dose by the mouth be very large (15 grains), the pulse is 
depressed. Full doses in fever therefore act as vascular sedatives. 
(For the action of quinidine on the heart see Therapeutics.) 

Blood.— After poisonous doses the blood is more coagulable than 
normal, but in medicinal amounts no such effect is produced. The 
effect of quinine on the blood corpuscles is of great interest. Even 
in full medicinal doses it arrests diapedesis of the white cells from the 
capillaries by a direct action on these cells, and if the drug be applied 
to the mesentery of a frog the cells already extruded cease their move- 
ment, but the intravascular cells do not. On the other hand, if qui- 
nine be given internally in so small a dose that the proportion to the 
blood is as 1 to 20,000, the white cells in the vessels cease to migrate, 
but those cells in the surrounding tissues do not (Binz, Hare, Dissel- 
horst, Ikeda) . It is stated, however, that this is not the case with all 
animals. This is perhaps the explanation of the effects of quinine 
in acute inflammations, for it arrests inflammatory exudation and 
allows the extruded cells to wander from the diseased area. Wilson 
and also Mainwaring and Ruh have shown that small doses of quinine 
equalling 2 to 3 grains of the sulphate distinctly increase the phago- 
cytic power of the blood, and that very large doses, more than 4 grains, 
circulating in the blood, distinctly decrease this power. This is 
another scientific confirmation of the belief of many practitioners 
that quinine aids the body in combating infections. Medicinal 
amounts gradually increase the number of red blood corpuscles. 

Respiration.— Upon respiration quinine acts as a slight stimulant 
in small doses, but as a marked depressant in poisonous amounts. 

Temperature.— Quinine lowers body temperature in health very 
little if at all, and in fevered states its influence is governed by the 
cause of the fever. Thus in malarial fevers quinine is a powerful 
indirect antipyretic, by reason of its powers over the infection, and 
not because it has any influence over heat production and dissipation. 

Absorption.— Quinine is absorbed from the stomach and duo- 
denum where it is dissolved by the bile, not from the lower intestine, 
where it is precipitated by the alkaline juices of the bowel. For 
this reason it should be given in cachet, capsule, or powder, rather 
than in compressed tablet, so that it may be absorbed before it reaches 
the jejunum. Pills should be freshly made. 

Kidneys, Elimination and Tissue-waste.— Quinine escapes from 
the body chiefly through the kidneys, although some of it is destroyed 
by oxidation in the liver and tissues. In the urine it is found as 
quinine and a dihydroxyl quinine. The excretion of quinine is by 



222 DRUGS 

no means rapid. Thus Jeanselme and Dalimier have shown that 
when it is given intravenously it appears in the urine at once and is 
present in this fluid for approximately twenty-seven hours. When 
given intramuscularly it appears in fifteen minutes and continues 
present for fifty hours, and given by the mouth it appears in the 
urine in twenty-five minutes and persists for thirty hours. This test 
can be made by means of Tanret's solution 1 if the urine is filtered and 
does not contain albumin, and will respond in the presence of T ^-g- mg. 
Ten cc of urine are placed in a test-tube and the reagent added drop 
by drop. The urine containing quinine, or its derivative, becomes 
opalescent, then opaque and finally flocculi are deposited. 

Upon tissue-waste quinine acts as a depressant and decreases the 
elimination of nitrogenous materials. 

Digestive Tk act.— Quinine has a bitter taste in as small a pro- 
portion as 1 : 10,000 of water. Upon the stomach it acts as a tonic and 
stimulant, but if given too frequently, or in large doses, it may irritate 
this viscus. Moderate doses are slightly constipating, and very large 
doses may induce colicky pain. 

Poisoning and Untoward Effects.— Severe poisoning from quinine 
rarely occurs, except in persons who have an idiosyncrasy to the drug. 
Roberts has recorded the case of a woman, aged thirty-six years, who 
took 5 drams (20 grams) and survived, after suffering from deep coma, 
shallow breathing, slow pulse, absolute deafness, and blindness. The 
loss of sight lasted two weeks, but the retinal changes persisted for 
several months. Death from an overdose of quinine is exceedingly 
rare. The cases in which death has followed its use are medical 
curiosities. Bouchardat has recorded the case of an adult male who 
died as a result of taking from 45 to 65 grains of the drug. That this 
was the real cause of death is doubtful. Soullier quotes Tarnier and 
Budin as asserting that enough quinine may be eliminated by the milk 
to produce death in a nursling. This seems hardly possible. 

"Untoward effects" is the best term with which to qualify the dis- 
agreeable symptoms which sometimes come on in persons having an 
idiosyncrasy to the drug and who are in reality poisoned by small 
doses. In these cases, sudden, complete, but temporary blindness 
is met with. De Schweinitz has seen it occur after a dose of 15 grains 
given in divided doses during twenty-four hours. He has also shown 
that in dogs quinine produces in continued toxic doses constriction 
of the retinal arteries, and permanent optic atrophy; and Holden has 
proved that there is degeneration of the nerve-fibers and ganglion cell- 
layers of the retina. When the dose is a single one recovery of vision 
usually occurs, but if the quinine has been continued after the symp- 
toms appeared the prognosis is not favorable. In other instances 
complete deafness asserts itself, due to congestion of the middle ear, 
while skin eruptions, generally of the nature of erythema, are not 
rarely seen. In other instances petechial and vesicular eruptions 

1 Tanret's solution is composed of potassium iodide 3.32, mercuric chloride 1.35, 
acetic acid 20 and distilled water 64. 



CINCHONA 223 

are developed, and swelling of the gums with a tendency for them 
to bleed may appear (Schulz). After lethal doses hemorrhage into 
the middle ear may be found, and severe epistaxis may ensue after 
so small a dose as 4 grains (0.25). The buzzing in the ears can gener- 
ally be relieved by the administration of 10 grains (0.60) of bromide 
of sodium combined with a little ergot. Karamitsas has stated 
that quinine may produce hemoglobinuria in persons suffering from 
malarial poisoning, and apparently may even develop bilious remit- 
tent fever. 1 (See below.) Irritability about the neck of the bladder 
may sometimes be produced by quinine, particularly in children. 

Therapeutics.— Quinine is employed in medicine to fulfil one great 
office, although its influence in other directions is by no means slight, 
namely, to destroy the malarial parasite. It may also be employed 
as an antipyretic, and as a tonic possessing peculiar virtues. 

For many years physicians employed this drug empirically, not 
knowing the cause of the disease called malaria. We now know that 
the theory of Binz, advanced as long ago as 1867, is correct, and that 
malaria is due to the presence of a parasite, the Plasmodium malaria 3 , 
which was first accurately studied by Laveran and named by Marchia- 
fava and Celli. These and other investigators have found that 
quinine acts as an active poison to these parasites, even in so weak a 
solution as 1 : 20,000. The direct effect of quinine upon the three 
forms of the malarial parasite has been studied by a number of investi- 
gators, chiefly by Romanowski, Mannaberg, Marchiafava, and our 
own Craig (U. S. Army). Craig states that if quinine is given when 
the young intracorpuscular parasites of the tertian variety are present 
there at once follows a great increase in ameboid movements, followed 
in an hour by an arrest of this movement. The parasite now becomes 
ring-shaped, or spherical, and much more sharply outlined than in the 
parasite not affected by the drug, and its protoplasm becomes very 
refractive and granular. In those parasites which succeed in advanc- 
ing to the stage of segmentation in spite of the quinine the young 
segments undergo fragmentary degeneration. The effect of quinine 
upon the full-grown tertian parasite before segmentation takes place 
is to cause the organism to shrink, to become granular, and the pig- 
ment bodies to become motionless. An important practical thera- 
peutic fact is that if one large dose is given just before a chill it destroys 
many of the young parasites, but if not all these then those which 
escape rapidly attack new blood cells; whereas if repeated doses of 
quinine are given every three or four hours all the parasites are 
destroyed. 

When the quartan parasite is attacked by quinine the same quicken- 
ing of ameboid movement, followed by arrest and by fragmentation 
and granular degeneration, ensues, but the young parasites seem to be 
more susceptible, so fewer escape than in the case of the tertian 
organism. 

1 See collective investigation of this subject by the author in Therapeutic Gazette 
for July, 1892; also article in New York Medical Record, January 7, 1899. 



224 DRUGS 

As to the estivo-autumnal parasite, Craig states that the hyaline 
or "ring" forms become very much more refractive and sharply 
denned under the effect of quinine. Their ameboid movements are 
greatly increased and they move rapidly from one place to another in 
the red cell. Marchiafava and Bignami assert that they even escape 
from the red cell. Fragmentary degeneration of the estivo-autumnal 
parasite is said not to occur. In this type of infection the use of 
quinine at regular intervals of three or four hours is particularly 
important. 

When malarial patients relapse the cause lies in improper use of 
the drug, or to the fact that some of the parasites are hidden in the 
bone marrow or spleen, or to the fact that by frequent small doses the 
parasite has become immune to quinine. Ehrlich stated that in the 
latter cases an injection of neoarsphenamine will at once cure the 
patient but other clinicians have found it inefficacious unless given 
with quinine. (For dosage in chronic cases see Intermittent Fever.) 

For the reasons given in the preceding paragraphs quinine is the 
best remedy for malarial fever as a prophylactic and cure, and it 
should be given in doses which are indicated by the state of the 
patient. (See Administration and Intermittent Fever.) If possible 
it should always be preceded by a purge having an hepatic action. 
This preliminary treatment is particularly important in bilious or 
remittent fever. The drug should be given in one or two large doses 
in such a way that its influence is fully exercised, not only at the time 
of the expected paroxysm, but also an hour or thirty minutes before 
that time and every four hours thereafter. If the paroxysm is near 
at hand, the drug should be given in solution, bitter though it be, in 
acidulated water. If the attack be so far advanced as the sweating 
stage, it should be given, nevertheless, to destroy the spores just set 
free. The free use of the drug to arrest a given paroxysm or series 
of paroxysms is not sufficient. Quinine should be given freely not 
only until all paroxysms cease but even after the examination of the 
blood fails to show any evidence of infection. (The student must 
read the article in Part IV, on Intermittent Fever at this point.) 

As a prophylactic against malaria the dose of quinine should be 2 
to 4 grains (0.12-0.25) or more three times a day, but in this use of 
it there is danger of producing a strain of parasites immune to quinine 
and, therefore, difficult to eradicate. (See Intermittent Fever.) 
This is important to remember not only from the standpoint of the 
individual patient but in respect to "carriers" since from them the 
mosquito may spread the infection to others. 

In hemorrhagic malarial fever quinine sometimes seems to do more 
harm than good. Under such circumstances the danger in using 
quinine consists in irritating the engorged kidneys after the chill has 
passed. Quinine is not a hemostatic, and only does good in malarial 
hematuria by destroying the parasite which produces the bloody 
urine. In hematuria occurring in persons broken in health as a result 
of chronic malarial infection, quinine is of no value unless an examina- 



CINCHONA 225. 

tion of the blood reveals the presence of parasites. To give quinine 
after this symptom appears is to "lock the door after the horse is 
stolen" unless the parasites are found in the blood. Many studies in 
America, Greece, and Italy indicate that the use of quinine is capable 
of developing a hematuria. 1 (See Hematuria.) If, however an 
examination of the blood reveals the malarial parasite, the drug 
should be freely used. Malarial hemoglobinuria is probably not 
caused by quinine, but is probably due to an associated parasite. 

In pernicious malarial fever quinine should be given by the mouth, 
as much as 60 to 70 grains (4.0-4.6) being used, or intramuscularly 
and intravenously. (See Administration and Intermittent Fever.) 

For the reduction of the pyrexia of typhus or typhoid fever quinine 
is inferior to the newer antipyretics, even when given in very large 
dose, and it ought to be used rarely, if at all, for this purpose. In 
all fevers it will seldom cause a fall of temperature before crisis or 
lysis, but will aid in the fall after these changes have begun. 

As a tonic quinine acts not only as a simple bitter, but also seems to 
have a direct effect in increasing the number of the red cells. The 
tonic dose should be 1 to 2 grains (0.06-0.12) three times a day. 

Quinine has been used to overcome uterine inerta in weak women, 
but it is a feeble remedy, and is seldom resorted to by progressive 
obstetricians. (See Kola.) Indeed some obstetricians believe that 
it increases the danger of post-partum hemorrhage. It will not of 
itself cause abortion, but in nervous, hysterical women who have a 
tendency to abort, and to whom it is necessary to give full doses of 
quinine during pregnancy, it may be well to combine some sedative, 
as one of the bromides or opium, with the antiperiodic. 

In cases where prolonged mental or physical strain is to be under- 
gone, quinine in the dose of 2 to 4 grains (0.12-0.25) will often prevent 
exhaustion and support the system. 

The use of quinine may be resorted to in whooping-cough, and the 
proper dose is 1| grains (0.08) for each year of the child's age, to be 
given at 6 a.m., 2 p.m., and 10 p.m. 

A much more agreeable method of pursuing this treatment in 
whooping-cough is to give the patient the so-called quinine chocolates, 
which contain 1 grain (0.06) of tannate of quinine and chocolate in 
each. The taste of quinine in such chocolates is scarcely noticeable 
if they are well made, although the after-taste is bitter. 

Used in solution in the form of a spray by the atomizer, quinine is 
of undoubted sendee in whooping-cough, and will often prevent the 
spread of the disease to other children if they be subjected to its use. 
This solution should contain from 1 to 2 grains (0.06-0.12) to the 
ounce (30.0) and be employed every few hours. As Mallory and 
others have shown that the germ of whooping-cough grows in the 
epithelial cells at the root of the tongue the quinine may exercise a 
direct germicidal effect. The bitter taste can be to some extent dis- 

1 See collective investigation of this subject by the author in Therapeutic Gazette 
for July, 1892; also article in New York Medical Record, January 7, 1899. 
15 



226 DRUGS 

sipated by the use of a cream peppermint drop before and after 
treatment. 

High rectal injections of quinine in the strength of 1 : 2000 are 
useful in amebic dysentery, as this drug destroys the Amoeba coli. 
Rogers and other eminent Oriental practitioners advise that in 
amebic abscess of the liver the pus be removed by aspiration and the 
cavity filled by the injection of a solution of 30 to 40 grains (2.0-2.6) 
of bihydrochloride of quinine. By this means the cavity usually 
sterile except for the ameba is kept sterile, and the patient avoids a 
serious operation when exhausted. 

Quinine and urea hydrochloride has been proved to possess marked 
power in the production of local anesthesia in five to twenty minutes 
when injected in solution into subcutaneous or submucous tissues. 
It may also be applied in solution to mucous membranes for this 
purpose. The anesthesia may last from four to six hours or even 
several days when the drug is injected. For operative work it is 
employed in exactly the same manner as cocaine. It seems very 
efficient and is not as toxic as is cocaine. (See Coca.) The strength 
of the solution for infiltration anesthesia varies from 0.25 to 1 per cent., 
the weaker one usually giving the best results, as the stronger one 
sometimes causes the formation of an indurated area where injected. 
For local application 10 to 20 per cent, solutions are employed. 
Solutions ready for hypodermic use are now placed on the market in 
sterile ampoules. 

Quinidine sulphate in the dose of 5 to 6 grains (0.4) three times a 
day has the power of overcoming auricular fibrillation in about 50 per 
cent, of cases and in nearly all greatly diminishes the degree of filbril- 
lation. Usually the rate of the ventricles quickens as the auricular 
fibrillation decreases. It is unwise by its use to decrease the ventric- 
ular beats below 200. It produces its effects by increasing the 
refractory period of the auricular muscle but unlike digitalis it does 
not slow the heart by a vagus effect for it depresses or paralyzes 
these nerves as does atropine. Although this tends to increase the 
ease of passage of impulses over the atrioventricular area such an 
effect is counterbalanced by a direct diminution of conducting power 
in His' bundle. As we still are ignorant of all that quinidine can do 
in these cases it should not be used except its effects can be watched 
by the aid of the electrocardiograph. It is contraindicated if the 
heart is weak. 

Administration.— When prescribing quinine the physician should 
employ the hydrochloride (Quinince Hydrochloridum, U. S. and B. P.), 
as it contains a high percentage of alkaloid and is very soluble in 1 to 
18 of water. An acid hydrochloride (Quinina? Dihydrochloridum, 
U. S., Quininxe Hydrochloridum Acidum, B. P.) is also official, and 
possesses the advantage that it is soluble in less than its own weight of 
water. The hydrochloride of quinine is stronger in alkaloid than the 
bisulphate of quinine (Quinince Bisulphas, U. S.), which is, however, 
soluble in the proportion of about 1 to 9 of water. The hydrobromide 



CINCHONA 227 

of quinine (Quinince Hydrobromidum, U. S.) is another useful salt, 
which is soluble in the proportion of 1 to 40 of water. The valerate 
of quinine (Quinines Valeras) possesses no particular value. Quinines 
Salicylas, U. S., is also official. The sulphate of quinine (Quinince 
Sulphas, U. S. and B. P.), the least soluble of all these salt, is by cus- 
tom most commonly administered. Quinince Tannas, U. S., is a salt 
not so bitter as the other salts, and is weaker in relative alkaloidal 
strength. One grain (0.06) of the tannate equals about \ grain (0.015) 
of pure alkaloid. The bisulphate equals about f and the sulphate f 
grain of the pure alkaloid. The dose of the salts of quinine varies 
from 1 to 4 grains (0.06-0.25) as a tonic, and from 4 to 60 grains 
(0.25-4.0) for antimalarial purposes. 

The B. P. recognizes a pill of quinine, Pilula Quinince Sulphatis, 
a tincture (Tindura Quinince), a wine (Vinum Quinince), and an 
ammoniated tincture (Tindura Quinince Ammoniata) . 

In regard to the administration of quiniue, it may be said that it 
should never be given in solution if it can be avoided, because of its 
disagreeable taste, but if its prompt absorption is essential this is the 
best way to use it. If it is given in solution, the liquid should be well 
acidulated, as under these circumstances it will not taste so bitter as 
when a weakly acidulated solution is employed and it is more rapidly 
absorbed. In adults and children quinine should be used preferably 
in small capsules or in pills, which may be gelatin-coated or sugar- 
coated. Another means for adults is the use of cachets. If pills 
are employed, care should be taken that the sugar is not hardened by 
age, and if capsules are used that the gelatin is thin, for if the pill or 
capsule escapes into the intestine before it is dissolved the quinine is 
precipitated and is not absorbed. If the case is that of a child too 
young to take a pill, the drug may be given in the following manner 
without tasting very disagreeably: 

1$ — Quininse hydrochloridi gr. xvj (1.0) 

Fluidextracti glycyrrhizse f 5j (4.0) 

Syrupi aurantii f 5ij (60.0). — M. 

S. — A teaspoonful t. i. d. for a child of three years. 

Tannate of quinine chocolates may be used, but even if they are 
well made the after-taste of quinine is marked. The rectal use of 
quinine is hardly justifiable. Little is absorbed and rectal irritation 
is prone to occur. 

' Quinine should be given by the hypodermic needle only when the 
infection is so severe as to endanger life or when the stomach is too 
irritable to retain the drug, and if the need is so urgent the intraven- 
ous method is preferable. (See page 229.) If given hypodermically, 
the injection should be intramuscular, because it is less prone to cause 
abscess and severe pain, and also because it will be more rapidly 
absorbed from the muscular tissues than from the subcutaneous 
tissues. One of the great muscles of the back is to be chosen. When 
given by the needle the best salt is the dihydrochloride, often called 
the acid hydrochloride, which is very soluble (about 1 part to 1 of water). 



228 DRUGS 

The ordinary dose when given in this manner is 10 grains (0.65) . The 
greatest possible precautions as to the maintenance of rigid asepsis 
of the skin, the needle, the syringe, the solution, and even of the 
salt itself is essential to avoid abscess. Further, the solution must 
not be concentrated, but dilute, because in concentrated solution 
quinine damages the tissues and destroys the phagocytes which 
ordinarily hurry to a damaged area to destroy any pathogenic organ- 
isms which may gain access to the devitalized spot. In India a 
considerable number of cases of tetanus have followed the intramuscu- 
lar use of quinine. A useful way of using this salt is to employ a 
solution in sterile water put up in glass ampoules, ready for use, con- 
taining about 4 grains (0.25) each, or 

T$ — Quininae hydro chloridi gr. iijss (0.15) 

Urethani gr. ij (0.06) 

Aquae destillatae ■ f 3j (4.0). — M. 

This solution is said to keep indefinitely. 

When the dihydrochloride is not at hand, the hydrochloride of 
quinine may be used, as it is soluble in about 18 parts of water, and 
contains more of the alkaloid than the more soluble bisulphate of 
quinine. It may be employed in the following manner: 

1$ — Quininae hydrochloridi gr. vij (0.5) 

Glycerini, 

Aquae destillatae aa f3ss (2.0). — M. 

S. — Warm solution before using it, and do not add acid. 

3 — Quininae hydrochloridi gr. xv (1.0) 

Alcoholis lUxv (1.0) 

Aquae destillatae f 3iss (6.0). — M. 

S. — Add a drop of dilute hydrochloric acid to complete solution before using. 

If the bisulphate is used intramuscularly, to its solution should be 
added a little tartaric or sulphuric acid to prevent precipitation of the 
drug in the alkaline juices of the connective tissue before it can be 
absorbed. The tartaric acid should be present in the proportion of 
about 1 grain (0.06) to each 5 grains (0.3) of the quinine. The hydro- 
bromide of quinine, the solubility of which is about 1 to 40 of water, 
may also be used intramuscularly, as may also the bimuriate of 
quinine and urea (Quinince et Urece Hydrochloridwn, U. S.), which, 
however, is scarcely more than half as strong in quinine as the other 
salts. All of these injections are painful except the last and all may 
cause sloughing, particularly if pathogenic bacteria are in the body. 

Baccelli used the following solution for intravenous injection of 
quinine in severe cases of malarial infection. 

fy — Quininae hydrochloridi . . gr. xv (1.0) 

Sodii chloridi gr. xv (1.0) 

Aquae destillatae . . f 3iiss (10.0).— M. 

S. — This should be injected, after an ounce (30.0) of distilled water has been added 
to it. The solution should be boiled and filtered, and used while warm. 



CINCHONA 229 

McLean, Michael and other surgeons in the United States Navy 
have strongly advocated the intravenous injection of strong quinine 
solutions in malaria and even in cases of malarial hematuria in which 
the parasite is found in the blood. The dihydrochloride may be 
dissolved in sterile water so that each cc contains 1 grain. Of 
this solution 10 or 15 cc (10 or 15 grains of the drug) are injected 
in each dose. The solution should be freshly prepared and well 
sterilized. The needle is then inserted through the wall of a vein 
distended by the use of a tourniquet, the skin being first painted with 
tincture of iodine. As soon as blood appears, proving the vein has 
been entered, the syringe, which has been previously charged, is 
attached and the fluid injected very slowly. A sense of flushing of the 
surface of the body ensues sometimes accompanied by dizziness. 
Some headache may develop. The patient should lie down for a few 
minutes. Doses may be given once or twice a day. Less reaction, 
due to the small amount of water used, is met with than when bulky 
solutions are employed. 

Sulphate of cinchonidine (Cinchonidince Sulphas, U. S.) is very 
useful in influenza combined with salicin or one of the newer salicy- 
lates. 

The dose of quinidine sulphate (Quinidince Sulphas) is about twice 
that of quinine, as is also that of cinchonine sulphate (Cinchonince 
Sulphas, U. S.) and cinchonidine sulphate (Cinchonidince Sulphas, 
U. S.). 

Chinoidinum is a resinous mass obtained in the preparation of the 
alkaloids of cinchona, and contain amorphous alkaloids. It possesses 
distinct antiperiodic power, and was used freely when quinine was a 
very expensive drug. Its dose is three or four times that of quinine. 

The liquid preparations of cinchona are the infusion (Infusum 
Cinchonce), dose a wineglassful (30.0); the tincture (Tinctura Cin- 
chona, U. S. and B. P.), one or two teaspoonfuls (4.0-8.0); and the 
compound tincture (Huxham's) (Tinctura Cinchona Composita, U. S. 
and B. P.), a teaspoonful to a tablespoonful (4.0-16.0). Tincture 
of cinchona should contain from 0.8 gram to 1.0 gram of cinchona 
alkaloids in each 100 cc. Huxham's tincture is a most efficient and 
elegant bitter tonic in debility and convalescence from low fevers. 
It is too weak in alkaloids to be used in malarial infection. Under 
the name of Elixir Roborans, or Whytt's tincture, a similar mixture 
is employed for the same purposes. The other liquid preparation is 
the fluidextract (Fluidextractum Cinchona, U. S., or Extractum Cin- 
chonce Liquidum, B. P.), which contains from 4 gram to 5 gram of the 
cinchona alkaloids in each 100 cc, dose 5 to 15 minims (0.3-1.0). A 
solid extract (Extractum Cinchonce) is given in the dose of 5 to 10 
grains (0.3-0.6). The B. P. preparation not official in the U. S. P. 
is the Infusum Cinchonce Acidum, dose § to 1 fluidounce (15.0-30.0). 

Contraindications.— Quinine is contraindicated in gastritis, cystitis, 
meningitis, epilepsy, cerebritis, and middle-ear disease, because it con- 



230 DRUGS 

gests, irritates, or stimulates those areas which are diseased, and is also 
contraindicated in those cases which have an idiosyncrasy to its action 

CINCHOPHEN. 

Acidum Phenylcinchoninicum, U. S., is used as a remedy for gout 
and was introduced into medicine under the trade name of Atophan. 
It is phenyl-quinolin carboxylis acid. (See Neocinchophen.) 

CINNAMON. 

Cinnamon (Cinnamomum Saigonicum vel Zeylanicum, U. S.; Cinna- 
momi cortex, B. P.) is the inner bark of a plant, a native of Ceylon 
or of the species indigenous to China. It contains a volatile oil and 
tannic acid. In overdose the oil acts as a soporific and kills by failure 
of respiration. 

Therapeutics.— Cinnamon is used, as are all the drugs of its class, 
for flavoring, as a carminative, and as an intestinal stimulant in serous 
diarrheas. It has the peculiar power of acting as a hemostatic in 
uterine hemorrhage where the flow is oozing and not active, thereby 
differing from the other volatile oils, with the exception of that of 
erigeron. The oil of cinnamon is a powerful antiseptic, which can be 
used in dilute form in the dressing of wounds and by injection in 
gonorrhea. 

Cinnamic acid, a derivative of oil of cinnamon, is also used for the 
same purposes; but its chief employment has been in the treatment of 
tuberculosis. This consists in injecting hypodermically and intramus- 
cularly 2 minims (0.1) of the acid. The injection produces burning 
pain, which soon disappears. The patient, however, feels fatigued, 
has vertigo and cerebral congestion. Gradually the dose is increased 
to 15 minims (1.0), and after several weeks the patient is said to cough 
less, to gain in weight, and to improve in physical signs. The treat- 
ment is so painful that it has not gained favor. 

Administration.— The dose of the oil (Oleum Cinnamomi, U. S. 
and B. P.) is 1 to 5 minims (0.05-0.3); of the water (Aqua Cinna- 
momi, U. S. and B. P.) a wineglassful (30.0) or less; of the spirit 
(Spiritus Cinnamomi, U. S. and B. P.), 5 to 30 minims (0.3-2.0); 
of the tincture (Tinctura Cinnamomi, U. S. and B. P.), \ to 1 dram 
(2.0-4.0). Under the name of Pulvis Aromaticus, U. S. (Pubis 
Cinnamomi Compositus, B. P.) a carminative powder, consisting of 
cinnamon 35 grams, nutmeg 15 grams, cardamoms 15 grams, and 
ginger 35 grams, is official. The B. P. preparation does not contain 
nutmeg. Aromatic powder is useful in the treatment of the flatulence 
of adults and children. The latter should take about 10 grains (0.6) 
at a dose, an adult 30 grains (2.0). 

Pulvis Aromaticus also enters into the composition of Fluidextrac- 
tum Aromaticum, U. S., which is given in the dose of 10 to 60 minims 
(0.6-4.0). 



CLOVE 231 

CITRIC ACID. 

Citric acid (Acidum Citricum, U. S. and B. P.) is chemically iden- 
tical with the acid of the lemon, but has not identical influences upon 
the body with lemon-juice. It is a tribasic organic acid usually pre- 
pared from the juice of limes or lemons and should not contain less 
then 99.5 per cent, of pure citric acid. It occurs in colorless, trans- 
lucent, right-rhombic prisms; odorless; having an agreeable, purely 
acid taste; efflorescent in warm air, and deliquescent when exposed to 
moist air. 

Citric acid is soluble in 0.5 part of water, and in 1.8 parts of alcohol 
at 25° C. (77° F.); in about 0.4 part of boiling water, and in 30 parts 
of ether. Not only does the lemon owe its acidity to this acid, but 
most of the other edible fruits, such as strawberries and raspberries, 
depend upon its presence for their acidity. 

Therapeutics.— Citric acid has been used in scurvy, or scorbutus, as 
a prophylactic and cure but pure lemon-juice is better, probably 
because it contains vitamines. In order to keep lemon-juice from 
decomposition on long voyages, it should be heated, pasteurized and 
poured while hot into bottles until it nearly reaches the cork; the 
remaining space is then filled with a thin layer of hot sweet oil and the 
bottle corked and stood upright. Under these circumstances the 
juice may be kept indefinitely. If the juice is boiled the vitamine 
content may be destroyed. 

Wright claims that because of the excess of calcium salts in cows' 
milk its prolonged use may predispose cases of typhoid fever to throm- 
bosis by increasing the coagulability of the blood. Five grains of 
citric acid given several times a day may be used to prevent this state, 
since it diminishes this tendency by removing the excess of calcium. 
If, however, the citric acid is used too constantly, it has been found 
that it may also increase the coagulability of the blood. For this 
reason it should be used every second or third day and not every day. 
Addis claims that Wright's views are erroneous, and the matter is still 
to be decided. I agree with Addis. 

In rheumatism, either acute or chronic, lemon-juice may be employed 
in the dose of 1 to 2 ounces (30.0-60.0) four times a day, well diluted, 
or 2 drams (8.0) of citric acid may be given. The acid is also of 
value in hepatic inactivity and catarrhal jaundice. (See Citrate of 
Potassium.) 

The preparations containing citric acid are Syrupus Acidi Citrici, 
U. S.; Succus Limonis, B. P., and Syrupus Limonis, B. P. 

CLOVE. 

Clove {Caryophyllus, U. S.; Caryophyllum, B. P.) are the dried 
flower buds ot Eugenia aromatica, a plant of the East and West Indies. 
They possess an aromatic odor and the pungent taste of a typical 



232 DRUGS 

spice. They contain a volatile oil (Oleum Caryophylli, U. S. and 
B. P.), which is yellow when fresh, but very dark in color when old. 
It should contain 80 per cent, of Eugenol, U. S. 

Therapeutics.— Clove, or its oil, is used in medicine for its car- 
minative effect. It is also employed as a stimulant and tonic to the 
stomach, to prevent griping during an attack of diarrhea, or that 
caused by purgatives, to act as a flavoring agent, as a counterirritant, 
as a parasiticide, and as a local anesthetic. 

The oil of clove possesses great power for good in many cases of 
pulmonary tuberculosis when cough and expectoration are excessive, as 
it greatly diminishes the quantity of sputum expectorated. It should 
be given in the dose of 5 minims (0.3) in capsule 1 hour after food 
three or four times a day, or a hypodermic injection of sterilized 
almond oil, containing in each dose of 30 minims (2.0) 5 minims (0.3) 
of the oil of clove, should be administered once a day. The injection 
should be given into the subcutaneous tissues of the flank or abdomen, 
and is painful, but the decrease in the cough and expectoration amply 
repays the patient for the pain. 

Like all volatile oils, this oil is an efficient local application for pedi- 
culosis pubis and similar parasitic affections. It may be used in tooth- 
ache because of its anesthetic powers, placed on a pledget of cotton in 
the cavity of the aching tooth. In the treatment of myalgia or mus- 
cular rheumatism, oil of clove is often placed in a liniment for its 
counterirritant effect. Doses of \ to 1 minim (0.03-0.06) of the oil in 
a little water will sometimes control excessive vomiting. In addi- 
tion to the oil the B. P. has an official infusion, Infusum Caryophylli, 
the dose of which is \, to 1 fluidounce (15.0-30.0). 

In overdose oil of clove acts as a soporific, and kills by failure of 
respiration and the production of severe gastro-enteritis. 

COCA AND COCAINE. 

Coca is the dried leaves of Erythroxylon coca, Lamarck (Fam. 
Erythroxylwa?) , known commercially as Huanuco coca, or of Erythro- 
xylon truxillense, Rusby, known commercially as Truxillo coca, which 
yields, as a rule, about 0.5 per cent, of the ether-soluble alkaloids of 
coca. Coca in the U. S. P. of 1880 was known as Erythroxylon. 
Cocaine (Cocaina, U. S. and B. P.) ; Cocaine Hydrochloridum, U. S. 
and B. P.) is the alkaloid derived from Erythroxylon. When cocaine is 
heated with hydrochloric acid it is split into several substances, among 
others a base called ecgonine, which has wholly different properties 
from cocaine, and is perhaps responsible for some of the evil effects 
which have resulted from improperly prepared cocaine. It is to be 
distinctly understood that Erythroxylon coca is not the same as 
chocolate or Theobroma cacao. 

Physiological Action.— Coca and its alkaloid cocaine, when taken 
internally, produce in some persons a sense of exhilaration and 



COCA AND COCAINE 



233 



pleasure. Often muscular and mental activity is temporarily 
increased under their influence. When locally applied to a mucous 
membrane, cocaine causes blanching followed later by marked 
congestion. 

Nervous System.— The dominant action of cocaine, when locally 
applied to the peripheral sensory nerves, is to paralyze them (Fig. 36) . 
When taken internally it stimulates the brain to an extraordinary 
degree, but exercises no effect upon the sensory nerves unless given in 
poisonous doses. Sometimes its internal use produces a decrease of 
sensation, which Mosso believes to be due to an influence on the spinal 
cord. This effect is, however, very feeble. If the dose be a poisonous 
one, convulsions of cerebral origin ensue, and are both clonic and 
tetanic in type. 

Upon the muscles, when taken intern- 
ally, Mosso has proved the drug to be a 
direct stimulant, and it is particularly 
active after starvation or fatigue. Mus- 
cular power is increased temporarily by 
cocaine by setting free reserve energy. 

Circulation.— Cocaine in moderate 
amounts acts as a stimulant to the heart 
and vasomotor center, but its effects are 
not marked except in almost poisonous 
dose. 

Respiration.— The drug acts as a 
powerful respiratory excitant, producing 
in large dose a great increase in the rapid- 
ity of the respiratory movements, but in 
poisonous dose it kills by failure of respir- 
ation associated with exhaustion from the 
accompanying convulsions. 

Temperature.— Cocaine raises bodily 
temperature to an extraordinary degree 
if given in overdose, this rise being due to 
an increase of heat-production (Reichert). 
inal amounts it has no such effect. 

Kidneys, Elimination, and Tissue-waste.— The drug is elimi- 
nated by the kidneys, but is chiefly destroyed by oxidation in the 
body. Under its influence the quantity of urine passed is increased 
and the nitrogenous elements eliminated in this fluid are slightly 
diminished. 

Eye.— Owing to its powerful action as a local anesthetic, cocaine has 
been used largely in diseases of the eye, and it is particularly effi- 
cacious in this organ because of the delicacy of the conjunctiva, which 
it readily penetrates and so paralyzes the peripheral sensory nerve- 
endings. The anesthesia comes on in from one to five minutes after 
the use of the drug, according to the strength of the solution used. 




Fig. 36. — A, sensory nerve 
supplying mucous membrane 
(J5) , which is anesthetized by 
cocaine, paralyzing the ends of 
the sensory nerve at B when 
locally applied. 



In moderate or medic- 



234 DRUGS 

When cocaine is applied to the eye, it causes distinct enlargement of 
the palpebral fissure and an apparent prominence of the eyeball. 
' This is due to a stimulant effect of the cocaine upon the sympathetic 
nerve fibers which supply the unstriped muscle fibers of the lids. 
Accompanying this effect, there is marked dilatation of the pupil, 
which Koller asserts is due to constriction of the bloodvessels of the 
iris, the muscular fibers being unaffected. ' Ophthalmologists, how- 
ever, generally assert that this mydriasis is due to the fact that the 
drug stimulates the peripheral ends of the sympathetic nerves. It is 
important to remember that this dilatation, unlike that produced by 
mydriatics, such as atropine, is not accompanied by paralysis of 
accommodation, and the dilatation of the pupil can be overcome at 
once by the use of eserine or pilocarpine. The drug does not cause a 
forcible mydriasis, and is never used for the prevention of adhesions 
in iritis unless combined with atropine. 

Therapeutics.— Cocaine hydrochloride (Cocaince Hydrochloridum, 
U. S. and B. P.) is used as an anesthetic in the eye in the strength 
of from 3 to 5 or more minims of a 1 to 4 per cent, solution. The 
strength of 2 and 3 per cent, is perhaps most commonly employed. It 
is worth remembering that cocaine is soluble in fats, whereas its salts 
are not. Cocaine itself should therefore be used in anesthetic salves, 
and may be used for this purpose in an oleate (Oleatum Cocaines) 
which contains 5 per cent, of cocaine. The local anesthetic effect of 
cocaine is materially increased by using adrenalin solution (1 : 5000 to 
1 : 1000) with it. This combination also decreases the danger of 
systemic effects being produced by cocaine, since the constriction of 
the bloodvessels by the adrenalin prevents the absorption of the 
cocaine. This prevention of the dissipation of the cocaine through 
absorption also increases the local anesthetic effects of the latter drug. 

The conditions indicating its use in the eye are all operations of a 
painful character, and it may also be used for the relief of pain, 
when an acute inflammation or foreign body is causing suffering. The 
following formula will be found useful in these states: 

1$ — Cocainse hydrochloridi gr. viij (0.5) 

Acidi borici gr. vij (0.46) 

Aquse destillatse foj (30.0) .— M. 

S. — Use with a dropper in the eye every fifteen minutes until relieved. 

Cases of keratitis are recorded in which cocaine has produced per- 
manent corneal opacities, and it may cause dryness and roughening of 
the corneal epithelium even in the normal eye. 

Cocaine has been used in 2 per cent, solution upon cracked nipples 
just before nursing, to relieve pain. The drug must be carefully 
washed off before the baby is put to the breast. It is asserted, how- 
ever, by Guenel and Desamaux that this treatment may permanently 
stop the flow of milk. 

Owing to the density of the mucous membranes of the vagina and 
rectum, cocaine has little effect upon them unless used in 10 per cent. 



COCA AND COCAINE 235 

solution and freely applied. In the mouth cocaine may be used in 
cases of stomatitis where a spot is to be cauterized and in pharyngitis. 
While it gives much temporary relief in pharyngitis, the subsequent 
effects are often exceedingly disagreeable, the congested area looking 
more angry and being more painful than before. In coryza and hay 
fever a powder consisting of cocaine, morphine, and bismuth in the 
proportion of 1 part each of the two alkaloids and 5 parts of the bis- 
muth will often be of service if snuffed into the nostrils. If cocaine 
be applied to a large nerve-trunk, amputation of the tributary limb 
may be performed without pain, but so large an amount of the drug 
must be used that there is great danger of poisoning the patient. 

Cocaine is often used at present in the place of ether in cases 
requiring amputation of the fingers or in cases of minor surgery where 
the action of the drug can be confined to the part injured. A cord 
should be tightly bound around the base of the finger and a 4 to 8 
per cent, solution injected into the part, the ligature about the base of 
the digit being used to prevent hemorrhage and systemic absorption of 
the drug. After the operation is completed slight hemorrhage should 
be allowed to occur, to sweep out the drug and thereby avoid a sys- 
temic effect. Not more than | grain of cocaine should be injected. 
When operations on a foot or hand have been done under cocaine 
anesthesia, and larger amounts than this have been used, the con- 
stricting bandage should be allowed to remain in place some time, since 
the tissues destroy the drug, so that when the bandage is removed 
less is absorbed. (Holscher and others.) 

When a limb is to be amputated under cocaine, the main supplying 
nerve should be exposed by the aid of infiltration anesthesia (see 
below), and then the nerve- trunk is to be anesthetized by the injection 
into its sheath of so weak a solution of cocaine in normal saline fluid 
as 1 per cent. 

Under the name of " infiltration anesthesia" Schleich has introduced 
a method of abolishing sensation in localized areas which often gives 
good results for minor operations. He injects into the skin, as super- 
ficially as possible, a sufficient amount of a solution of common salt, 
cocaine, and morphine to produce local edema, and thereby pressure 
on the nerve filaments, which are also depressed by the cold liquid 
coming in contact with them. He also believes that the local anemia 
so caused aids in decreasing sensation. The injection is given so 
gently that a sort of wheal or edematous spot is produced where the 
incision is to be made. As soon as this spot is developed the needle is 
inserted into its margin and carried under the skin a little farther, and 
then the injection is repeated. In this way the line of an extensive 
incision can be anesthetized progressively. If deep incisions are 
necessary, the injections are made into the deeper tissues as well. 
The injections must always be made into healthy skin, as if it is 
diseased a slough may result. Schleich asserts that similar injections 
under the periosteum permit of operations on the bones. The anes- 



236 



DRUGS 



thesia lasts twenty-six minutes. The solution is of three strengths 
as follows: 



Solution. 


I. 


II. 


III. 


Cocaine hydrochloride 


. gr. iv (0.25) 


gr. ij (0.12) 


gr. | (0.012)' 


Morphine hydrochloride 


. gr. | (0.03) 


gr. § (0.03) 


gr. T V (0.006) 


Sodium chloride . 


. gr. iv (0.25) 


gr. iv (0.25) 


gr. iv (0.25) 


Sterilized distilled water 


. fSiv (120.0) 


f Siv (120.0) 


f Siv (120.0) 




To each of these solutions 3 minims of a 5 per cent, solution of 
phenol are added. The second solution is the one commonly used. 
The first is employed where acute inflammation is present, and the 
third where repeated injections are necessary. (See Fig. 37.) The 

effect of these injections is considerably 
emphasized if adrenalin chloride in the 
proportion ofjjl : 20,000 is added to the 
mixture. 

For minor localized operations it is 
very satisfactory; but for long and deep 
incisions it is of little value, as its effects 
are inadequate unless doses so large as 
to be poisonous are employed, and be- 
cause it in no way diminishes the fear 
and mental suffering of the patient, in 
whom the dread of the operation is 
worse than the actual pain. Under 
certain circumstances, however, it may 
be used in major surgery, such as tra- 
cheotomy, the removal of small super- 
ficial tumors, and in those patients who 
are so profoundly ill that it is dangerous 
to use a general anesthetic, as, for ex- 
ample, in intestinal perforation in typhoid 
fever, an operation which has been done 
many times with this method. As the 
operation proceeds the deeper tissues are 
anesthetized by infiltration if possible, 
and are cut, not torn, as the tearing produces great pain. Great care 
is necessary that the fluid injected is sterile. (See Procaine.) 

In place of Schleich's fluid the following plan is now commonly 
followed: A tablet containing f grain (0.045) of cocaine hydro- 
chloride with T J 7 grain (0.00015) of adrenalin chloride is dissolved in 
50 cc of normal salt solution. Another similar tablet is dissolved 
in 100 cc of normal saline. The stronger solution is used to infil- 
trate the skin and the weaker to infiltrate the looser and deeper tissues 
as the operation proceeds. Fill a 2 cc Record syringe armed with 
a fine needle for the injection of the stronger fluid and a 5 cc Record 
syringe with a large and coarser needle for the weaker fluid. Precede 
the infiltration anesthesia by half an hour with from 0.1 to J grain 



Q 



Fig. 37. — Infiltration anesthe- 
sia. The needle is inserted at 
each successive point as num- 
bered until the line of anesthesia 
is complete. 



COCA AND COCAINE 237 

(0.006-0.016) of morphine and -^inr (0.0003) of scopolamine given 
hypodermically, and if the patient is restless or suffers pain during 
the operation repeat this dose. The operator must not hurry but 
give the injected fluids time to act as he proceeds from tissue to tissue. 
(See Scopolamine-morphine Anesthesia.) 

Cocaine and eucaine (see also Alypin, Stovaine, and Tropacocaine) 
have been used to produce anesthesia of large areas of the lower 
portions of the body and limbs by injecting them into the subarach- 
noidean cavity below the termination of the spinal cord by means of 
a long hollow needle, so-called spinal anesthesia, but, as the toxicity 
.of these drugs is greater than some of the other local anesthetics, 
they have been supplanted by the newer drugs of this class. (See 
Stovaine and Procaine.) 

Internally, cocaine or the fluidextract of coca may be used as a 
temporary supportant and stimulant in low fevers, and in cases where 
great physical and mental strain must be borne. Its use for any 
length of time is dangerous and harmful. Thorington has found 
cocaine of great value in yellow fever as a stimulant for a short time 
and as an antiemetic. In the vomiting of pregnancy and other forms 
of excessive emesis it is of great service by depressing the gastric sen- 
sory nerves and thereby decreasing the irritability of the stomach. 

Cocaine is stated to be an antidote to acute morphine poison- 
ing. 

Cocaine is undoubtedly of service in the opium habit, but if con- 
tinuously used soon changes the patient from a morphinomaniac to 
a "coca fiend," and for this reason should not be employed. 

The dose of the fluidextract (Extractum Coca? Liquidum, B. P.) is 
from J to 1 dram (2.0-4.0), and it should contain 0.5 Gm. of ether- 
soluble alkaloids in each 100 cc. The dose of cocaine is from \ to 
\ grain (0*015-0.03). The other B. P. preparations are Lamella? 
Cocaine, each disk containing -^ grain (0.0012) of cocaine hydro- 
chloride, and Unguentum Cocaina? and Injectio Cocaina Hypodermica, 
given in the dose of 1 to 10 minims (0.06-0.6). 

The cocaine habit is a condition unfortunately frequently met with 
since the introduction of this drug into therapeutics. It is often com- 
bined with the morphine habit, and sometimes cocaine is employed as 
a substitute for morphine. The symptoms of the cocaine habit con- 
sist of marked loss of flesh, disorders of the circulatory system, mental 
failure, and delusions sometimes resembling those of chronic alcohol- 
ism. Often disagreeable hallucinations are present. The habit is 
difficult to cure, for relapses are frequent and mental and physical 
degeneration takes place far more rapidly than when morphine is 
abused. The sudden withdrawal of cocaine from a patient may result 
in profound collapse. 

According to Magnan, a pathognomonic symptom of chronic or 
subacute cocaine intoxication is a sensation under the skin of a crawl- 
ing worm or bug. 



238 DRUGS 

Untoward Effects.— Loss of speech, blindness, nausea and vomiting, 
syncope, and unconsciousness have followed the internal use or 
local application of cocaine. Epileptiform convulsions have also 
been noted, while the circulation and respiration have been disordered 
in every possible manner. In many of these cases the urine passed 
after the poisoning has been copious, limpid, and contained albumin. 
Curiously enough, a large number of cases of severe poisoning have 
followed the injection of cocaine into the urethra previous to opera- 
tion for the relief of chronic gonorrhea or stricture. 

These symptoms may ensue in susceptible persons after the use of 
quantities received with impunity by others. Thus, they have fol- 
lowed the instillation of 20 minims of a 10 per cent, solution, but 
recovery has ensued after the ingestion of 15 grains (1.0) by the mouth. 

The hypodermic injection of cocaine sometimes causes vomiting. 

Of 250 cases of accidental poisoning arising from the medicinal 
use of the drug but 13 proved fatal. 

The treatment of the poisoning consists in the use of ammonia, 
coffee, strychnine, or ether and alcohol if the symptoms are those of 
depression. If they are convulsive in type, then the treatment to be 
instituted is identical with that of strychnine poisoning (which see). 

Reichert asserts that morphine is the best antidote to cocaine 
poisoning. 

CODEINE. 

Codeina, U. S. and B. P., soluble in water 1 to 120, is an alkaloid 
derived from opium, or is prepared from morphine by methylation. 
It is often contaminated by morphine. The sulphate of codeine 
(Codeince Sulphas, U. S.) is generally used, as it is more soluble than 
codeine itself. Codeine sulphate is soluble in 30 parts of water. 
Codeine phosphate (Codeince Phosphas, U. S. and B. P.) is also official, 
and is soluble in 2.3 parts of water. 

Physiological Action.— Codeine resembles morphine very decidedly 
in its physiological action, the chief difference being that it possesses 
less narcotizing power, but in large amount it more readily produces 
tetanus and final paralysis of the peripheral motor nerves in the lower 
animals (Dott and Stockman). It does not arrest secretion in the 
respiratory and intestinal tract, as does morphine, and therefore does 
not directly check expectoration and is less apt to cause constipation. 

Therapeutics.— Codeine has been highly recommended for years as a 
nerve quietant in nervous cough and in cases where the cough is exces- 
sive in bronchitis and phthisis. In diabetes mellitus some clinicians 
have found it of value, while others have been disappointed in its 
use. It should, however, always be tried in this disease if there is 
insomnia and great nervous irritability, in the hope that it may exer- 
cise a favorable effect. When given for obstinate cough it should 
be used in the dose of from T V to J grain (0.006-0.02) three or four 
times a day, in the syrup of wild-cherry bark. When given for 



COD-LIVER OIL 239 

diabetes the dose should be much larger, beginning at 1 or 2 grains 
(0.06-0.12), and rapidly increasing it until the glycosuria is dimin- 
ished. Sometimes as much as 20 or 30 grains (1.3-2.0) or more may 
be given daily. The B. P. recognizes a syrup. (Syrupus Codeinoe 
Phosphatis) given in the dose of 1 to 2 drams (4.0-8.0). 



COD-LIVER OIL. 

Oleum Morrhuce, U. S. and B. P., sometimes called Oleum Jecoris 
Aselli, is a fixed oil obtained from the fresh livers of Gadus morrhua, 
or cod-fish. There are several species of cod from which the oil is 
obtained other than the one named, but that given is the chief source 
of supply. The oil is pale or dark according to its freedom from for- 
eign materials. Although the paler oils are generally prescribed, there 
can be little doubt that the darker ones are more medicinally active. 
The most prominent inorganic constituents of the oil are iodine, 
bromine, and sulphuric and phosphoric acids. It also contains more 
or less of the biliary salts. 

Lofoten cod-liver oil, obtained from cod caught near the Lofoten 
Islands, is generally considered the best for medicinal use. 

Physiological Action.— Cod-liver oil depends on a number of sub- 
stances for its peculiar effect. The iodine certainly exerts definite 
alterative powers, and the oil seems peculiarly adapted to digestion 
and absorption, for cod-liver oil passes through animal membranes 
very readily, probably owing to the biliary salts contained in it. 

Investigations of the last few years have shown that a large part 
of its value is due to its high content of fat soluble vit amine A which 
is in part destroyed or diminished if the oil is too greatly purified 
in order to make it more agreeable. 

The oil aids in the maintenance of bodily temperature by its oxi- 
dation, and causes a deposit of fat in the tissues. It also seems to 
influence the blood directly, for clinical observation shows that anemic 
persons become healthy-looking under its use, and Cutler and Brad- 
ford have found that this apparent improvement is a physiological 
fact, the red corpuscles being always increased. It has been proved 
by experiment that cod-liver oil is more readily oxidized than any 
other oil. 

The belief among physicians that the effects of cod-liver oil are 
dependent upon some peculiar combination of substances has shown 
itself in the attempts of physiological chemists to isolate the combina- 
tion. One of the best results reached is the so-called "morrhuol," 
a crystalline substance containing phosphorus, iodine, and bromine: 
3 to 5 grains of this preparation are said to represent 1 dram of 
the pure oil, and it is certainly of value as a medicament in most of 
the states in which the oil itself is used. In " colds" which "hang on" 
and are not readily gotten rid of, morrhuol is best given in capsule or 



240 DRUGS 

pill. This substance is put on the market in gelatin-coated pills or 
capsules. It does not possess the nutritive value of the oil itself. 

Therapeutics.— Cod-liver oil is useful in those persons who have no 
tubercular lesion in the lung or other tissues, but have mucous mem- 
branes which are very susceptible to disease. This state has been 
called the pre-tubercular stage of phthisis. Cod-liver oil possesses no 
curative power in cases of well-developed and rapid phthisis, and its 
administration in many cases serves only to nauseate the patient or to 
produce an oily diarrhea through failure of digestion. It does good 
in the early stage of the disease in that it acts as a food peculiarly 
suited to a wasting malady, and its mild alterative effects are also of 
value. It maintains the patient's strength and general nutrition, and 
so favorably influences the pulmonary lesion, provided it can be 
taken in addition to good food. If it destroys the appetite or dis- 
orders the digestion it is very harmful. In chronic rheumatism the 
drug is often of great service, particularly if the disease is largely 
muscular. Skin lesions depending for their existence upon general 
malnutrition and anemia, often yield to its use. In enlargement of 
the lymphatic glands, where they are not undergoing acute active 
suppuration, cod-liver oil given internally does good. This is a 
statement requiring explanation. By acute active suppuration is 
meant the early formation of pus or the molecular death of the 
parts— not the slow formation characterized by no active change, but 
represented by cold abscess or old sores. If the suppurative process 
is chronic, the oil does good by maintaining the patient's nutrition. 
In cases of strumous ophthalmia cod-liver oil is of great service. In 
advanced syphilis cod-liver oil is most useful, and in all stages 
of rickets it ought to be employed. In marasmus, when used by 
inunction, or given internally if the stomach will stand it, it is one of 
the best drugs we have. In a few grains of bile-salts, consisting of 
glycocholate and taurocholate of sodium, be added to each dram 
of oil, it will be more readily absorbed, from the skin when applied 
by rubbing, or when taken internally. 1 Another method, to aid its 
absorption, is to mix 1 part of liquid soap with 2 parts of the oil before 
it is rubbed into the skin. 

In sciatica and lumbago and in neuralgia cod-liver oil is of service, 
if those disorders are dependent upon anemia or an impoverished 
state of the system. In emphysema of the lungs it is said to be of 
value, and certain writers commend its use in gout, although others 
have asserted that it is of no value. Sometimes old persons, whose 

1 These salts may be bought, or made as follows: To about 300 cc of ox-gall is 
added nearly thrice that quantity of ordinary alcohol, and the flask shaken thoroughly. 
All the mucus is now precipitated and the supernatant fluid is filtered. To the filtrate 
is added a large excess of sulphuric ether, and after a time a plaster-like mass forms 
at the bottom of the vessel, which slowly becomes crystalline. These crystals are 
now placed on a filter-paper and washed with a mixture made of ether and alcohol, 
equal parts. The filter-paper is dried and the substances then seen are the tauro- 
cholate and glycocholate of sodium. Having carefully removed these salts from the 
paper, they are ready for use. 



COD-LIVER OIL 241 

digestion is not disordered and who have no organic brain disease, 
complain of giddiness. The best treatment for this condition, in 
many cases, is cod-liver oil with small doses of quinine, or if these fail 
ergot and one of the bromides may be used. 

Administration.— Owing to its disagreeable taste and smell most 
patients rebel against taking cod-liver oil; but these objections can, 
with a little persistence, be readily overcome, so that finally the 
patient may not object to the remedy, but actually like it. This is 
particularly true of young children. The secret of reaching this much- 
to-be-desired state lies in the use at first of doses which may be 
dropped into a teaspoon and the spoon then gently submerged in a 
glass of milk. The oil floats off onto the milk in a globule in the center 
of the tumbler, and if the milk be rapidly gulped down without the 
oil touching the sides of the glass, it will not be tasted. The first 
gulp must be large enough to include the oil. The oil may be taken 
on a full stomach, but as a general rule it is best digested if taken 
about two or three hours after meals, when the gastric contents are 
about to be passed into the small bowel, where the oil is digested; 
and if it be immediately followed by a little pancreatin, its digestion 
will be much aided. Other modes of ingestion consist in the placing 
of the oil in whisky or brandy, in the manner which has been described 
with milk. This method possesses the advantage that the alcohol 
by its stimulating effect aids very distinctly in the digestion of the oil. 
Sometimes a pinch of salt placed in the mouth before and after the 
oil is taken aids in masking its taste and in its digestion. (See 
Indigestion.) Oil of eucalyptus in the proportion of 1 to 100 of the 
cod-liver oil will disguise the latter' s taste, but many persons dislike 
the eucalyptus more than the cod-liver oil. The addition of an equal 
quantity of glycerin, with J to 1 minim (0.025-0.05) of the oil of bitter 
almonds to each dose, is often of service. Syrup of bitter orange peel 
is one of the best masks to its taste. Tomato ketchup has also been 
used with' good results. Chewing a piece of smoked herring before 
and after taking the oil is of value to disguise the taste in some cases. 
The oil is readily taken in soft capsules holding from \ to 1 dram 
(1.0-4.0). Few patients are unable to swallow such capsules if these 
are first made slippery by dipping them in water. 

Cod-liver oil is most readily digested when given in single nightly 
doses after supper or after a light meal just before going to bed. After 
a few days it may be given after dinner, and in the course of a week 
after breakfast. If the patient is once nauseated by overdoses, it is 
almost impossible to make the stomach retain the oil. If there is diffi- 
culty in digestion, a dram of ether aids in its absorption or a drink 
of whisky or brandy may be used instead. Often a simple bitter, 
such as a dessertspoonful (8.0) of compound tincture of cardamom, 
taken in water immediately after the oil is swallowed, aids in its 
digestion. 

A large number of preparations of cod-liver oil are on the market 
16 



242 DRUGS 

in emulsion, pancreatized, and purified until they are nearly tasteless. 
Emulsion Olei Morrhuce containing 50 per cent, of oil, given in the dose 
of 2 to 4 fluidrams (8.0-16.0). Many of the permanent or perfect 
emulsions contain more Iceland moss or acacia than oil. The pan- 
creatized emulsions are the best if the oil is present in sufficient quan- 
tity to do good, as the very fact of the oil being artificially emulsified 
adds to its value and makes it possible to put more oil into the emul- 
sion. Oil devoid of smell is probably devoid of medicinal value, as all 
the peculiar properties have been "purified" out of it. 

It has been suggested that cod-liver oil be given by the rectum, a 
full dose of pancreatin being mixed with it to increase its assimilability. 
This is almost useless. Sometimes creosote is placed in this injection 
in 5- to 10-minim (0.3-0.6) doses to prevent decomposition changes 
in the oil and, after absorption, to act as an expectorant. 

COFFEE. 

(See Caffeine.) 

COLCHICUM. 

Colchicum is the dried corm (Colchici Cormus, U. S. and B..P.) and 
seed (Colchici Semen, U. S.; Colchici Semina, B. P.) of Colchicum 
autumnale, or meadow saffron, a plant of Europe, containing an 
alkaloid, colchicine (Colchicina, U. S.), which may be still further 
changed into colchiceine. The drug is official in the form of the seeds 
and root. Colchici cormus should yield not less than 0.35 per cent, 
of colchicine. Colchici semen should yield not less than 0.45 per cent, 
of colchicine. 

Physiological Action.— Colchicum is a very powerful drug, and when 
locally applied is an irritant to the skin. Taken internally in overdose 
it severely irritates the gastro-intestinal mucous membrane. 

According to the studies of one of the writer's students— Dr. 
Ferrer y Leon— the drug has little or no effect when given in mod- 
erate dose on the nervous system, circulation, respiration, or tem- 
perature, producing changes in these parts only when given in poison- 
ous doses. In full doses it greatly increases the flow of bile, and may 
cause bilious vomiting and purging. Jacobi asserts that death is 
produced by respiratory failure, the heart continuing to beat for many 
minutes after respiration ceases. The violent gastro-enteritis which 
is present in colchicum poisoning in man certainly has much to do with 
the usual fatal result. 

Therapeutics.— The employment of colchicum in medicine centers 
around its use in gout and similar states, such as chronic rheumatism. 
It is almost a specific in acute gout, provided that it be pushed until 
it causes slight griping or laxity of the bowels. Colchicum does not 
seem to possess any marked beneficial effect in preventing attacks. 



COLCHICUM 243 

Indeed, while it relieves one attack it often seems to hasten the onset 
of the next. In acute gout it is usually well to unload the bowels by 
a small dose of compound extract of colocynth, with some hyoscyamus 
added to it to stop griping. Thus 

T$ — Extracti colocynthidis compositi .... gr. x vel xx (0.6-1.3) 

Extracti hyoscyami gr. ij (0.12). — M. 

Fiant pilulae, No. iv. 

S. — One as soon as threatened by an attack. 

This pill is particularly needed if constipation be present and the 
belly hard. After this has acted, the colchicum may be given. 
Thirty to 40 minims (2.0-2.6) of the wine of the seeds should be given, 
and 20 minims (1.3) more in twelve hours. In some cases of subacute 
or chronic gout or chronic rheumatism, iodide of potassium should be 
used in conjunction with the colchicum. The following may be 
ordered : 

3 — Potassii iodidi 3ss vel 5J (2.0 vel 4.0) 

Vini colchici seminis f3ij (8.0) 

Vini albae q. s. fSiij (90.0).— M. 

S. — Tablespoonful (16.0) three times a day after meals. Shake well before using. 

The use of colchicum in such doses as to cause severe purgation or 
emesis is dangerous, and should not be resorted to. 

Colchicina, U. S., can be used successfully in gout in the dose of 
i^ro to -V (0.0006-0.0012) three to five times a day. There are 
now on the market capsules or pearls of colchicine with oil of gaul- 
theria, each pearl containing from yj-g- to -^ grain (0.0006-0.001) of 
colchicine. They are very efficacious and are largely used. 

Poisoning.— The symptoms of poisoning by colchicum are nausea, 
griping, agony in the belly, purging followed by the passing of thick 
mucus, with great and increasing tenesmus, profuse salivation, col- 
lapse, and death from exhaustion and gastro-enteritis. Bloody purg- 
ing is almost never seen. The poisoning is one of the most painful, 
slow, and hopeless poisonings known, and a man taking as much as 
an ounce of the wine of the root or the seed is almost inevitably 
doomed to a terrible death. Tannic acid may be used as a partial 
chemical antidote, and the stomach washed out by the administration 
of emetics and the use of the stomach-pump. Opium is to be used to 
relieve the pain and irritation, and oils are to be given to soothe the 
inflamed mucous membrane. If collapse comes on, external heat and 
stimulants are to be used, and atropine may prove of service under 
these circumstances. 

Administration.— Colchicum should never be used in substance, 
but may be employed in the form of wine of the seed (Vinum Colchici 
Seminis) in the dose of 20 to 40 minims (1.3-2.6), although if a 
marked effect is required 60 minims (4.0) may be used. The extract 
Extr actum Colchici Cormi, U. S.) is given in the dose of J to 2 grains 
(0.03-0.12) and should contain 1.4 per cent, of colchicine. The 



244 DRUGS 

fluidextract of the seed (Fluidextractum Colchici Seminis, U. S.) 
should contain 0.4 grams of colchicine in each 100 cc, and is given 
in the dose of 2 to 4 minims (0.12 — 0.25). 

The tincture of the seed (Tinctura Colchici Seminis, U. S. and 
Tinctura Colchici, B. P.) is given in 15- to 60-minim (1.0-4.0) doses, 
and should contain 0.04 gram of colchicine in each 100 cc. The B. 
P. dose is 5-15 (0.3-1.0). The other B. P. preparations are Vinum 
Colchici, dose 10 to 30 minims (0.6-2.0), and Extractum Colchici, 
dose J to 1 grain (0.015-0.06). 

Colchicine (Colchicina, U. S.) is given in pill in the dose of y^g to 
5-V grain (0.0006-0.0012). 

COLLODION. 

Collodium, U. S. and B. P., is a solution of gun-cotton or pyroxylon 
in alcohol and ether, and is a clear syrupy fluid, smelling strongly 
of ether. 

Therapeutics.— Collodion is used as an air-tight dressing for small 
wounds and abrasions and for rendering small dressings waterproof. 
A difficulty in its use consists in the contraction which takes place as 
it dries, which draws and puckers the parts sufficiently to cause not 
only discomfort, but also acute pain. It should be applied with a 
carneF s-hair brush. 

In boils, when they are beginning in a small pustule or papule with 
an inflamed zone, collodion painted around the spot, except at its very 
center, will generally abort the suppuration. If the boil has burst, 
this treatment is useless; but if it has not, the pus should not be liber- 
ated, but allowed to become inspissated. By this treatment and by 
the frequent application of a coat or two the local trouble eventually 
disappears. This rule applies only to certain cases, and if pain is 
caused by the retention of the pus, it must be evacuated with anti- 
septic precautions. In smallpox the flexible collodion may be used 
to prevent pitting. 

In gouty inflammations of the joints an application of collodion 
mixed with iodine, equal parts, will often diminish the pain, although 
at first the suffering may be increased by this treatment. 

Flexible Collodion. 

Flexible collodion {Collodium Flexile, U. S. and B. P.) is made by 
adding camphor 20 parts and castor oil 30 parts to 950 parts of ordi- 
nary collodion. It does not contract or become hard, and is generally 
to be preferred to ordinary collodion in the dressing of wounds. 

Styptic Collodion. 

Styptic collodion (Collodium Stypticum) contains tannic acid, and 
has been employed to check small hemorrhages. It is seldom used, and 
its employment is an unsatisfactory way of controlling bleeding. 



COLOCYNTH 245 

Cantharidal Collodion. 

Cantharidal collodion (Collodium Cantharidatum, U. S.) has been 
referred to under the head of Cantharides. Collodium Vesicans, B. 
P., is identical with this preparation, and is used for the same purpose. 



COLOCYNTH. 

Colocynthis, U. S., is the peeled dried fruit of Citrullus colocynthis, a 
plant at present largely grown in all parts of the world. It contains 
an alkaloid, colocynthine, and a resin. Neither of these is used in 
medicine. Colocynth causes large watery evacuations, and may, 
in very large dose, produce fatal gastro-enteritis. It is official in the 
B. P. as Colocynthidis Pulpa. 

Therapeutics.— Colocynth is never used alone, but always in com- 
binations with other drugs of its class as a hydragogue cathartic. 

In cases of chronic dropsy and for the relief of serous effusions this 
drug is generally given in the form of the compound extract of colo- 
cynth (Extractum Colocynthidis Compositum, U. S. and B. P.), which 
contains 160 grams of extract of colocynth, 500 grams of purified aloes, 
140 grams of the resin of scammony, 50 grams of cardamom, and 150 
grams of soap. In the dose of 5 to 20 grains (0.3-1.3) this acts as a 
powerful watery purge useful in dropsy. The extract (Extractum 
Colocynthidis, U. S.) is given with other drugs in the dose of 2 to 5 
grains (0.12-0.3) as a purge. The following is a useful form in which 
to administer it: 

1$ — Extracti colocynthidis gr. xxx (2.0) 

Extracti belladonna foliorum gr. ij (0.1) 

Extracti nucis vomica gr. ij (0.1). — M. 

Fiant pilulae, No. x. 

S. — One each morning. 

Colcynth is one of the principal ingredients in compound cathartic 
pills (Pilulce Cathartics Composite, U. S.). Each pill contains: com- 
pound extract of colocynth, If grains (0.08); resin of jalap, § grain 
(0.02); and calomel, 1 grain (0.06); gamboge, J grain (0.015). This 
pill is not to be used constantly, as it eventually makes the bowels 
more constipated than before. The U. S. P. of 1900 also ordered a 
pill (PUuIxb Cathartics Vegetabiles) which contained compound 
extract of colocynth, extract of hyoscyamus, resin of jalap, extract 
of leptandra, resin of podophyllum, and oil of peppermint. This is 
given in the dose of 1 to 2 pills and should not have been dropped. 

The preparations of the B. P. not official in the U. S. P. are: Pilula 
Colocynthidis Composita, composed of colocynth-pulp, aloes, scam- 
mony, sulphate of potassium, and oil of cloves, dose 5 to 10 grains 
(0.3-0.6); Pilula Colocynthidis et Hyoscyami, dose 5 to 10 grains 
(0.3-0.6). 



246 DRUGS 



CONDURANGO. 



Condurango is the bark of Condurango bianco, a tree of Colombia, 
South America. Martindale and Westcott state it is Gonolobus con- 
durango. It was introduced into medicine in 1873 as a cure for 
gastric cancer, and at one time had a favorable reputation. It is now 
known that, so far as the morbid growth is concerned, its action is 
valueless, but there is no doubt that it diminishes the severity of the 
symptoms in many cases by exercising a favorable effect on the gastric 
mucous membrane. It also tends to relieve the accompanying gastric 
catarrh through its action as a stomachic. 

The bark is never employed as the bark, but in the form of the fluid 
extract, dose 1 to 2 drams (4.0-8.0), or the wine, dose J to 1 ounce 
(16.0-30.0). Sometimes it is given in the form of a decoction made 
by adding 1 part of the bark to 8 parts of water, which is given in the 
dose of 1 tablespoonful (16.0) three times a day. Often it is advisable 
to add to the prescription a little hydrochloric acid to take the place of 
the natural acid of the stomach, which is usually lacking in such cases. 

CONIUM. 

Conium is the full-grown but unripe fruit of Conium maculatum. 
The plant grows in Europe and the United States, and contains 
a liquid alkaloid known as coniine. When kept for more than two 
years conium becomes unfit for use. 

Physiological Action.— Conium in full medicinal dose produces a 
feeling of relaxation and loss of muscular power, and if the dose be very 
large it causes giddiness, staggering gait, and disordered vision, with 
failure of the circulation. 

Nervous System.— Conium depresses the motor nerve plates, and, 
if the dose be extraordinarily large, the sensory nerves. Upon the 
spinal cord it exerts a slight depressing influence, but has no positive 
effect, while the fact that consciousness continues almost up to death 
shows that the intellectual portion of the cerebrum escapes its 
influence. 

Circulation.— The action of the drug upon the circulation is 
depressant. It causes at first a fall of arterial pressure; then, if the 
dose be large, a rise, due to the asphyxia caused by nervo-muscular 
failure of the respiratory apparatus. Finally, a fall of pressure takes 
place. 

Respiration is depressed because of the paralytic influence of the 
drug on the respiratory center and the nerve trunks supplying the 
respiratory muscles. 

Therapeutics.— Conium holds an unimportant place in the drug-list 
of today. It has little value except in spasms due to irritation of a 
nerve trunk, when it may be of service. In spasms of cortical or spinal 
origin other drugs should be used, as it is evident that conium has 



COXYALLARIA 



247 



no effect in quieting the central nervous protoplasm, but only pre- 
vents the impulses which are sent out from manifesting themselves 
in movements of the muscles. The powdered leaves or other prepara- 
tions may be smeared over poultices to relieve the pain of ulcers and 
cancers, and they certainly do good in such instances. 

Administration.— The dose of the alcoholic extract (Extractum 
Cvnii) is from \ to 1 grain (0.03-0.06). The dose of the tincture 
(Tinctura C<mii,B. P.) is J to 1 fluidram (2.0-4.0), B. P. Coniine is 
a liquid alkaloid which should never be used. The dose of the hydro- 
bromide of coniine is said by Helbing to be f to | grain (0.01-0.03). 
The preparation in the B. P. made from the leaves is Succus Conii, 
dose 1 to 2 fluidrams (4.0-8.0). 
Vapor Conii consists of the juice 
of hemlock (Succus Conii) \ ounce 
(15.0), liquor potassse 1 dram (4.0), 
and distilled water 1 ounce (30.0). 
Twenty minims (1.3) of this mixture 
are placed in hot water in an inhaler, 
and so employed for the relief of irri- 
tative coughs or spasmodic asthma. 
Unguentum Conii is official in the B. 
P., and is used in pruritus and. 

It is to be remembered that the 
variability of the drug, so far as 
power is concerned, is very great— 
so great as to make it unreliable. 
For this reason a small dose should 
be given at first and the amount 
gradually increased. 

Poisoning.— A prominent symp- 
tom of poisoning by conium is 
dropping of the eyelids (ptosis) , due 
to paralysis of the oculomotor 
nerves, and staggering and inability 
to walk. Its treatment consists in 

the use of strychnine as a respiratory and nervous stimulant, the 
employment of external heat, and the use of cardiac stimulants if 
the circulation fails. The stomach is to be emptied by emetics or 
the stomach-pump before the antidotes are used. 




Fig. 38. — -A, conium acts as a depress 
ant to the motor nerve trunks. 



CONVALLARIA. 

Convallaria is derived from the rhizome and root-stalks of Con- 
vallaria majalis. It is employed in medicine as a cardiac tonic to 
fulfil the indications which direct us in the use of digitalis. While 
by no means so valuable a drug as foxglove, it sometimes acts better 
in an individual case than the older remedy. The heart is not greatly 



248 DRUGS 

slowed by it, but the drug is particularly useful in cases of arrhythmia 
and "cardiac hurry." 

The dose of the fluidextract is from 4 to 8 minims (0.25-0.5) three 
times a day. The tincture (Tinctura Convallaria?) is given in the 
dose of 5 to 20 minims (0.3-1.3). Convallamarin is a glucoside of 
convallaria which has been used in the dose of \ grain (0.03) three 
times a day. Some clinicians think it ought to be given but once a 
day on account of the danger of cumulative action. 

COPAIBA. 

The Copaiba of the U. S. and B. P. is the balsam or the oleoresin 
of one or more South American species of Copaiba, and is a clear, trans- 
parent liquid of oily consistence, of a pale or brownish-yellow color 
and a peculiar odor. From it is distilled an oil which is of little value. 

As copaiba is an oleoresin, the term "oleoresin of copaiba" is often 
used to distinguish it from the oil. 

Therapeutics.— Copaiba is used for the purpose of stimulating the 
mucous membranes of the genito-urinary tract, particularly when they 
are depressed after a period of inflammation, as in the later stages of 
gonorrhea. In cases suffering from chronic urethritis with anemia 
and debility the following prescription is useful. (See also Methylene 
blue.) 

1$ — Oleoresinse copaibae 5J (4.0) 

Oleoresinae cubebae lUxx (1.3) 

Ferri et ammonii citratis gr. xx (1.3). — M. 

Pone in capsulas, No. x. 

S. — One t. i. d. after meals. 

Copaiba is employed in subacute and chronic bronchitis as a stimu- 
lant expectorant. In the treatment of subacute pyelitis, cystitis, and 
dysentery it is of value. In dropsy due to slow renal changes it is of 
service as a renal stimulant and diuretic. 

Administration. —Copaiba itself is given in the dose of 5 to 20 minims 
(0.3-1.3) in capsule or in emulsion. The oil of copaiba (Oleum 
Copaibce, U. S. and B. P.) is given in capsule or emulsion, preferably 
in the former, in the dose of 10 to 20 minims (0.60-1.3) two to four 
times a day. Sometimes it is dropped on sugar and so administered. 
Massa Copaibce is made by rubbing copaiba with magnesia, but this 
is a useless and clumsy way of using it in pill form. 

The drug is eliminated in the urine, and gives the test for albumin 
with nitric acid. 

Copaiba sometimes causes urticaria, which soon disappears on 
withdrawal of the drug. 

COPPER. 

Cuprum is never used in the form of the metal itself, but chiefly as 
the sulphate (Cupri Sulphas, U. S. and B. P.), which appears in com- 
merce as a blue, clear, somewhat efflorescent salt. It is soluble in 2.5 



COPPER 249 

parts of cold water, and 0.5 part of boiling water, but it is not soluble 
in alcohol. 

Physiological Action.— Copper sulphate, when locally applied to a 
mucous membrane, acts as a powerful astringent, or on the surface of 
an ulcer as a mild and superficial caustic. When given in overdose by 
the stomach, it causes death by violent gastro-enteritis and exhaus- 
tion. Generally the symptoms do not appear for an hour, and consist 
in burning pain in the stomach, a coppery or metallic taste in the 
mouth, followed by vomiting of bluish liquids and glairy mucus. 
With the vomiting, purging comes on, the passages at first containing 
the contents of the intestine, and finally mucus and blood. Convul- 
sions of an epileptiform character may be present, and constant and 
profuse salivation is not infrequent. After death fatty degeneration 
of the liver and kidneys has been noted, and it is not uncommon for 
jaundice to appear after the first twenty-four hours, if the patient 
survives so long. This jaundice is dependent upon changes in the 
blood. The treatment of the poisoning consists in the primary use 
of the chemical antidote, which is the yellow prussiate of potassium, 
and the administration of emollient or demulcent substances, such a 
sweet oil and white of eggs, followed instantly by emetics or the 
stomach-pump. If emesis and purgation are already active, emetics 
are of course contraindicated, counterirritation is to be employed 
over the stomach and intestines in the shape of a mustard plaster of 
moderate strength, and opium given to allay irritation and relieve 
pain. 

Chronic copper poisoning is almost never seen, and, although the 
metal is widely used for coloring canned green vegetables, it seems to 
be harmless when ingested in such small amounts. 

Therapeutics.— Sulphate of copper in the dose of 5 to 7 grains (0.3- 
0.46) may be used as a rapidly acting emetic which acts only upon the 
stomach, but not upon the vomiting center. As it is irritant, the 
emetic dose should not be repeated, but if emesis does not occur the 
sulphate of zinc or mustard should be used to empty the stomach. 
Indeed, it may be said of sulphate of copper that it should never be 
given as an emetic if any other emetic can be found. Thornton has 
proved in the Laboratory of Experimental Therapeutics of the 
Jefferson Medical College that an antidotal dose of copper sulphate 
given to a dog poisoned with phosphorus may produce death before the 
phosphorus can cause a lethal result. The drug is, therefore, a 
theoretical, but not a practical antidote to phosphorus. In pill form 
it is sometimes given in diarrheas depending upon ulceration of the 
bowels. The dose should be J to 1 grain (0.015-0.06) combined with 
opium. 

In amebic dysentery sulphate of copper (2 grains to the pint), which 
destroys the amebse, may be employed for irrigation of the colon in 
hot solutions (105°-110° F.) once or twice a day. (See Enterocylsis 
for method.) 



250 DRUGS 

In some states of the body, particularly in skin diseases of the dry 
type and in individuals with tubercular tendencies, copper seems to 
act like arsenic, and may be used in doses of yu grain (0.006) or less 
three times a day when arsenic is not well borne. In small doses it 
is said to be a direct stimulant to the tissues, and to increase the 
firmness of the flesh and strength of the normal man. Strong claims 
for copper as a remedy for anemia have been advanced, particularly 
if it is employed as the arsenite of copper, when the conjoint action 
of the arsenic and copper produces a good effect. 

Sulphate of copper in the proportion of 1 to 50,000,000 or 1 to 
5,000,000 has been proved to be exceedingly valuable for the purpose 
of purifying water potable except for the growth of algae, which make 
it foul. In these proportions it also destroys the typhoid bacillus, and 
it should be placed in all springs, ponds, or reservoirs which may be 
contaminated by these germs. In these quantities it is harmless to 
man and animals. 

Locally applied, sulphate of copper is useful, in the solid form or in 
powder, in the treatment of indolent idcers. In chronic conjunctivitis 
or in cases of tinea torn— that is, tinea on the margin of the eyelids— a 
crystal of the sulphate may be drawn over the diseased spot; or a 
solution of 1 to 3 grains (0.06-0.2) to the ounce (30.0) of water may 
be dropped into the eye in subacute conjunctivitis. 

In relaxed sore-throat, as a gargle, in the strength of 4 grains (0.25 
to the ounce (30.0), it is often of service. 

CORPUS LUTEUM. 

The yellowish body found at the site of a recently ruptured Graafian 
follicle in the ovary of a non-pregnant animal, usually the sow, has 
been introduced into medicine, in desiccated form, for the purpose 
of relieving symptoms associated with menstrual disturbances. It 
gives excellent results in relieving the nervous disturbances which are 
manifested during the artificial menopause due to removal of the 
ovaries. This substance also seems to do good in amenorrhea and 
scanty menstruation, particularly that occurring in overfat young 
women and in some cases of dysmenorrhea and menstrual migraine. 
It has also given good results in the vomiting of early pregnancy, but 
if. the blood-pressure falls under its use more than 15 points its 
administration should be stopped. It is contraindicated in exoph- 
thalmic goiter. 

The dose usually given is 5 to 20 grains (0.3-1.3) three times a day 
after meals, but, if need be, a far larger dose may be used, as it seems 
to be innocuous. It may be given in capsules or tablet form, or 
intramuscularly from ampoules containing 15 minims (1.0) of soluble 
extract, equivalent to 2.5 grains of the desiccated substance, once a 
day. It has also been used intravenously. The needle or syringe 
should be sterilized by boiling, as phenol impairs the drug. 



CREOSOTE 251 



. COTARNINE. 

Cotarnince Hydrochloridum, U. S., is prepared from narcotine, one 
of the alkaloids of opium, but its physiological effect is closely allied 
to that of hydrastinine, derived from hydrastis. In the form of 
cotarnine hydrochlorate it has been placed on the market as "Stypti- 
cin," and this is used as a remedy for oozing hemorrhages, such as 
menorrhagia and metrorrhagia, and as a local application in epistaxis. 
It may be given in the dose of from § to 4 grains (0.03-0.25) three 
times a day in pill, tablet, or elixir, or in capsule, or by the hypodermic 
syringe in the dose of 1 to 2 grains (0.06-0.12). 

CREOLIN. 

Creolin is a liquid cresol, a coal-tar product, possessing marked 
antiseptic but comparatively slight poisonous properties. It is a 
dark-brown fluid derived from soft coal, and is of the consistence 
of syrup. When added to water it forms a white cloud and mixes 
thoroughly, forming an emulsion up to 12 per cent, of the drug. 

Therapeutics.— Creolin is used as an antiseptic in the lying-in state, 
as a wash for the hands and for vaginal irrigation. It cannot be used 
as a solution in which to place instruments, as the mixture with water 
is so opaque as to prevent their being seen when lying at the bottom of 
the dish. When used as a vaginal douche it should be employed in the 
strength of 2 per cent. One of its properties which is of value is that 
it forms a slippery coating over the maternal parts during parturition. 
In the treatment of cystitis in the female, Parvin highly recommended 
it as a vesical wash in the strength of a 1 per cent, solution, or, after 
the bladder becomes accustomed to its use, in a 2 per cent, solution. 
According to Kretzschmar and others, a solution of 1 to 500, used with 
a syringe, is useful in otorrhea, 1 to 100 in nasal ulcers, and 1 to 1000 as 
a nasal douche in rhinitis when there is much discharge with the for- 
mation of crusts. Creolin has also been used as an injection in the 
proportion of 5 parts in 1000 of water for dysentery and colitis with 
success. 

A useful ointment for fetid sweating of the feet is— 

3— Creolin f 5J (4.0) 

Hydrargyri ammoniati gr. x (0.65) 

Acidi salicylici gr. x (0.65) 

Petrolati molli Sj (30.0).— M. 

CREOSOTE. 

Creosote (Creosotum, U. S. and B. P.) is a mixture of phenols and 
phenol derivatives, chiefly guaiacol and creosol, obtained during the 
distillation of wood-tar, preferably of that derived from the beech, 
Fagus silvatica, Linne, or Fagus ferruginea, Aiton (Fam. Fagacecs). 

It occurs as an almost colorless, yellowish (not pinkish), highly 



252 



DRUGS 



refractive, oily liquid, having a penetrating, smoky odor, and a burn- 
ing, caustic taste. It should not become brown in color on exposure 
to light. Its specific gravity should not be below 1.073 at 25° C. 
(77° F.). 

Its solution in about 140 parts of water at 25° C. (77° F.) is not 
perfectly clear. With 120 parts of hot water it forms a clear liquid, 
which, on cooling, becomes turbid from the separation of minute oily 
drops (distinction from, and absence of, both phenol and so-called 
"coal-tar creosote"). Much of that sold is derived from coal-tar, 
and is far less useful. Chemically, creosote is almost identical with 
phenol; clinically, it is very different. Its physiological action is 

almost identical with that of phenol, 
and in poisoning by creosote the 
same antidotes as are employed in 
phenol poisoning— namely, soluble 
sulphates— should be used, as has 
been proved in experiments by the 
author. Creosote contains 60 per 
cent, of guaiacol and 40 of creosol, 
not cresol. Guaiacol is sometimes 
used in place of creosote in the 
dose of 1 to 2 minims (0.05-0.10). 
(See Guaiacol.) Creosote is a 
powerful antiseptic. 

According to the studies of Im- 
bert, creosote is eliminated chiefly 
by the kidneys in the form of gua- 
iacol sulphate and creosol sulphate 
of potassium. Elimination is not 
rapid, for this investigator did not 
find it completed for about twenty- 
eight hours. A small amount of 
the drug is eliminated by the lungs. 
Therapeutics. — During the past 
few years creosote has been largely 
prescribed in pulmonary tuberculosis and chronic bronchitis, and some 
of the results reached by its use have undoubtedly been of value in 
these affections. (See article on Tuberculosis.) It has also been 
inhaled from sponges with great relief, and even has been injected 
into the lungs by way of the trachea or through the chest-wall. In 
the treatment of chronic bronchitis creosote may be placed in boiling 
water and inhaled in the steam. Under these circumstances it lessens 
the fetor of the breath, and this method often gives more rapid relief 
than any other measure in the treatment of ordinary subacute inflam- 
mation of the bronchi. (See Inhalations.) The beginning dose when 
the drug is given internally is 2 to 5 minims (0.1-0.30). 
It is useless to attempt to cure pulmonary tuberculosis by the 




Fig. 39. — Yeo's inhaler, made of 
perforated zinc, bound on the edges 
with chamois skin, and supplied with 
elastic loops to go back of the ears. 
On a sponge placed in front of the 
inhaler is dropped the medicament to 
be inhaled. 



CREOSOTE 253 

administration of creosote, and its chief value in the disease depends 
upon its action as an expectorant affecting favorably the profuse 
bronchial secretion associated so often with the involvement of the 
lung tissues by the tubercular process. Creosote does good, indirectly 
by relieving this complication; but it is apt to disorder the digestion. 
It ought not to be employed in every case, since its value in relieving 
the bronchial disorder is far outweighed by the disturbance of diges- 
tion in many instances. If fever or hemoptysis is present, the use of 
creosote is contraindicated. When it is desired to relieve profuse 
muco-purulent expectoration creosote may be given in capsule or as 
follows: 

3— Creosoti (beechwood) f 5iij (12.0) 

Tincturse gentianse compositae f 5j (30.0) 

Spiritus vini rectificati f§vii (240.0) 

Vini Xerici Oij (960.0).— M. 

S. — A tablespoonful in a wineglassful (16.0 : 60.0) of water three times a day. 

In other cases the creosote may be dropped into half a glassful of 
milk and taken in this three times a day. Often as much as a dram 
a day can be given by gradually producing tolerance through ascend- 
ing doses; and it is worthy of note that in most instances large doses 
are required if satisfactory results are to be obtained. (See article on 
Tuberculosis, Part IV.) 

In the advanced stages of phthisis inhalations of the drug often 
decrease the cough, relieve the laryngeal dryness, and promote expec- 
toration. 

In the treatment of subacute laryngitis a fine spray of 1 to 2 minims 
(0.06-0.12) of creosote, 4 grains (0.25) of menthol, and 1 ounce (30.0) 
of liquid albolene, is of service used several times a day; or a mixture 
composed of creosote 10 minims (0.6), chloroform spirit 10 minims (0.6), 
and alcohol 20 minims (1.3), may be placed on the sponge of an inhaler 
and inhaled. It is also claimed that wetting cloths with creosote and 
hanging them in the air of a nursery are of great value in whooping- 
cough. (For methods, see Inhalations, Part III.) 

Creosote is a valuable remedy in cases of indigestion with fermenta- 
tive changes in the gastric contents when these arise from the deficient 
digestion of meats or the use of sweets, given in the dose of J to 2 
minims (0.025-0.1) after meals, preferably in tablet or capsule. 
Applied on a pledget of cotton to the cavity of a carious tooth, 
creosote often relieves toothache by virtue of its anesthetic influence 
over peripheral sensory nerves. 

While ordinary medicinal doses of creosote rarely cause disagreeable 
symptoms, except some disorder of the stomach or bowels when it is 
given in full doses, the physician who is ordering large amounts should 
be always on the lookout for toxic symptoms. These consist in 
vertigo, headache, and a tendency to stupor, and the urine may 
become smoky in appearance, as in phenol poisoning. If any of these 
signs of overdosing appear, the drug must be reduced in dose or 
stopped altogether. 



254 DRUGS 

The preparations of creosote are Aqua Creosoti, U. S., which is 
given in the dose of 1 to 3 fluidrams (4.0-12.0); Mistura Creosoti, 
B. P., dose J to 1 fluidounce (15.0-30.0); Unguentum Creosoti, B. P., 
for local application. 

Creosote Carbonate. 

Creosotes carbonas, sometimes called " Creosotal," is a combination 
of creosote with carbonic acid. Over 90 per cent, of creosote carbon- 
ate is said to be creosote. It is a thick, oily fluid of an amber color, 
with but little taste or odor, and is insoluble in water, dilute alcohol, 
and glycerin, but is soluble in 95 per cent, alcohol, in ether, chloro- 
form, and in cod-liver and olive oils. It is said to be less irritating 
to the stomach than creosote. The drug is dissolved and absorbed 
chiefly in the intestine. The dose of creosote carbonate varies from 
15 to 30 grains (1.0-2.0) twice or thrice a day after meals. It is used 
as an expectorant in pulmonary tuberculosis and as an intestinal 
antiseptic. It is best given in capsule. (See also Guaiacol, Carbonate 
of.) It has been claimed that this drug possesses great virtue in 
cases of croupous pneumonia, but careful clinical research has failed 
to show that this is true. 

CROTON CHLORAL. 

Croton chloral, or Butyl Chloral Hydras, B. P., has a physiological 
action closely allied to that of chloral itself, but it possesses more 
analgesic power and is much less depressant to the heart and circu- 
lation. The dose for the production of sleep is the same as chloral, 
5 to 20 grains (0.3-1.3) in syrup. 

Therapeutics.— Croton chloral is preferable to chloral in sleepless- 
ness due to pain. 

In facial neuralgia and migraine it is exceedingly efficacious, par- 
ticularly if the fifth nerve be involved. In headaches due to eye- 
strain, and in those associated with sick stomach, but not due to gastric 
indigestion or nervous debility, croton chloral is of service. Curiously 
enough, it is valueless in toothache, but is useful in the neuralgia due 
to decayed teeth. 

Administration.— Croton chloral should be used in pill form in the 
dose of 3 to 5 grains (0.2-0.3) every two hours until the pain is relieved 
or sleep comes on, or it may be given in solution or syrup of acacia and 
water, or water and glycerin. It has been used in as large a dose as 
60 grains (4.0), but 20 to 30 grains (1.3-2.0) ought to be the maximum 
dose as a general rule. 

CROTON OIL. 

Croton oil {Oleum Tiglii, U. S.; Oleum Crotonis, B. P.) is an exceed- 
ingly irritant oil derived from Croton tiglium, a small tree of India. 
The oil is pale or brownish-yellow in hue and of a complex character. 



CUBEBS 255 

Applied to the skin for any length of time, it is an intense irritant, 
producing blisters or pustules. 1 minim (0.06), placed on the tongue 
with 5 minims (0.3) of sweet oil, acts as a violent watery purge, and, 
owing to the smallness of its dose, it is frequently employed to remise 
the unconscious, as in cerebral congestion. In delirium it is used for 
the same purpose, and may be given to maniacs who are suffering 
an attack of cerebral congestion or obstinate constipation, owing to 
the smallness of its dose and rapidity of action. The dose is 1 minim 
(0.06) placed on the tongue with sweet oil or given in emulsion or in 
pill. It should never be used when there is any irritation of the 
stomach or bowels. As a counterirritant it is sometimes applied over 
a tender nerve or to the chest in the treatment of bronchitis, in the 
proportion of half-and-half with sweet oil. Thus applied, it may be 
absorbed and cause purging. The treatment of poisoning by croton 
oil is identical with that of gastro-enteritis. (See Gastro-enteritis.) 
Linimentum Crotonis is a preparation of the B. P. which is employed 
as a counterirritant liniment for sprains and in muscular rheu- 
matism. 

CUBEBS. 

Cubebs (Cubeba, U. S., and Cubeba Fructus, B. P.) are the unripe 
fruit of Piper cubeba, a plant of Java. They are wrinkled or rough 
black bodies about the size of small peas, and have an aromatic, 
pungent taste. They contain a volatile oil, cubebic acid, and cubebin. 
The drug should not be kept in powdered form, as it loses its powers, 
but should be powdered as needed. Overdoses of cubebs cause gastro- 
intestinal and genito-urinary inflammation. 

Therapeutics.— Cubebs are used in the advanced stages of gonor- 
rhea when a tendency to a chronic discharge is present. Some sur- 
geons have used them in the early stages as an abortive treatment, but 
this is a bad practice. In cold in the head the powdered berries may 
be snuffed up the nostril when the stage of secretion is well estab- 
lished. They ought not to be used before this stage. In the treat- 
ment of chronic or subacute bronchitis the oleoresin of cubebs is very 
useful in some cases (see Bronchitis), and in the form of cubeb 
cigarettes the drug is much used as a remedy for hoarseness due to 
subacute laryngitis. 

Administration.— Cubebs may be given in powder in the dose of 10 
to 60 grains (0.6-4.0), as the fluidextract, 10 to 30 minims (0.6-2.0), 
and in the form of the tincture ( Tinctura Cubeba, B. P.) in the dose 
of 10 minims to J ounce (0.6-16.0), \ to 1 fluidrachm (2.0-4.0), B. P. 

The dose of the oleoresin (Oleoresina Cubeba, U. S.) is 2 to 20 minims 
(0.1-1.3) three times a day, and it may be given in capsule or emulsion. 
The troches of cubebs ( Trochisci Cubeba, U. S.) are used for the relief 
of pharyngitis of a chronic type. The dose of the oil (Oleum Cubeba, 
U. S. and B. P.) is 5 to 20 minims (0.3-1.3). 



256 DRUGS 



DIAL. 



Dial is a trade name for diallylbarbituric acid or diallylmalonylurea. 
It is a combination of two molecules of barbituric acid with the allyl 
radical (C 2 H 4 ) differing therefore from barbital in which the methyl 
radical occurs. It seems to be totally destroyed in the body but it is 
important to remember that as it lowers blood-pressure it must be 
used with care, if at all, in persons with a feeble circulation. It is 
without doubt an efficient hypnotic in cases of nervous insomnia 
given in the dose of 1 to 3 (0.06-0.20) grains in pill, tablet or capsule. 
It is to be noted that its dose is much less than that of barbital. 

DIASTASE. 

The word diastase (Diastasum, U. S.) is applied to substances 
found in certain of the digestive juices of the animal body and present 
in processes connected with the fermentation of grain, as, for example, 
in the manufacture of alcoholic beverages. Whatever diastase may 
be, we recognize that it belongs to the same class of enzymes as pepsin 
and pancreatin, and that it has the power of converting starch into 
dextrin. Many preparations of malt contain some diastatic power, 
but there is only one preparation of diastase which possesses no 
other property save that of aiding the digestion of the starches— 
namely, one prepared originally by a Japanese investigator, Taka- 
mine, and called from his name "Taka-diastase." It is used to 
relieve cases of indigestion of starchy foods in the dose of 2 to 5 grains 
after meals, in tablet or capsule or in a solution, and is a most efficient 
remedy. 

A useful formula is as follows: 

1$ — Taka-diastase gr. xlv (3.0) 

Pancreatini gr. xlv (3.0) 

Extracti nucis vomicae gr. iv (0.25). — M. 

Pone in capsulas, No. xx. 

S. — One capsule with meals. 

Often a little capsicum may be added to this prescription, in the 
treatment of atonic dyspepsia, with advantage. 

In the artificial feeding of infants it is often necessary to largely 
dilute the cows' milk and equally needful to maintain its nutritional 
value. This can be accomplished by adding barley gruel which has 
been strained and then largely converted into dextrin or maltose by 
adding taka-diastase to it while it is still warm, but not boiling hot. 
The diastase can be destroyed after its effects are induced by bringing 
the gruel to the boiling-point for a few moments. 

Taka-diastase, in the dose of 5 to 10 grains (0.3-0.6) three times a 
day, sometimes decreases the loss of sugar, and more frequently 
greatly diminishes polyuria in diabetes mellitus. 



DIGITALIS 257 



DIGITALIS. 



Digitalis, U. S., is the dried leaves of Digitalis purpurea, Linne, or 
Foxglove, collected from plants of the second year's growth, at the 
commencement of flowering. The leaves are official in the B. P. as 
Digitalis Folia. It contains a number of substances, no single one of 
which acts as do preparations of the crude drug. In other words, all 
these compounds must act together to produce therapeutic effects 
similar to those obtained when digitalis leaves are given. Among the 
substances so far isolated from digitalis by chemists may be named 
digitalin, digitalein, digitoxin, digitin, and digitonin. Several of 
these are probably compounds of the others. Digitalin, so-called, 
occurs in two forms, amorphous and crystalline. The crystalline 
digitalin (Xativelle, French) is largely digitoxin, while the amorphous 
form is composed of digitonin, digitalein, and digitalin. German 
digitalin is about 50 per cent, digitonin and 6 per cent, true digitalin. 
Digitoxin and pure digitalin are the two most active principles yet 
found. None of these substances should be used in medicine to take 
the place of digitalis, but digitalin and digitoxin may be used as a 
heart stimulant. (See Administration.) 

In the early part of this volume the necessity of employing reliable 
drugs was pointed out. In the instance of digitalis this is particularly 
important, because the cases in which it is used are often serious, and 
because digitalis varies greatly in strength. As a rule, the wild digi- 
talis is stronger than the cultivated, and the English or German digitalis 
is better than the American. The preparations of digitalis should 
therefore be obtained from a reputable manufacturing pharmacist 
after they have been physiologically tested. 

Physiological Action.— Digitalis is apt to irritate mucous membranes 
which are already slightly out of order, and for this reason should not 
be given by the mouth in large doses in cases of gastritis and allied 
states if it can be avoided. 

Nervous System.— The action of digitalis upon the nervous 
system is only manifested when poisonous doses are used. Small toxic 
doses decrease reflex activity by stimulating Setschenow's reflex 
inhibitory centers in the medulla, and finally by depressing the spinal 
cord. Convulsions are sometimes seen as a result of the action of 
decomposition products of digitalis— namely, toxiresin and digital- 
resin. Finally, the motor nerve- trunks themselves are depressed and 
the muscles are paralyzed. None of these effects are seen in man. 

Circulation.— Upon the circulatory system digitalis exerts its 
chief influence. In moderate or medicinal amounts it increases the 
pulse-force and arterial pressure, slows the pulse, and increases the 
size of the pulse-wave. The increase of pulse-force is due to a stimu- 
lating influence exercised upon the muscular fibers of the heart. 
Gottlieb and Magnus have shown this to result in the doing of two 
and one-half times the normal amount of work. 
17 



258 



DRUGS 



Not only does digitalis stimulate the ventricular wall to greater 
effort, and restore its tonicity when this is impaired, but the pro- 
longation of the period of diastole permits the heart to regain its 
irritability, contractility, and also the conductivity of- its muscular 
fibers. The longer the diastole, therefore (diastole being the period 
of resuscitation), the greater the power of the next contraction. 
(See below.) 




Fig. 40. — A, digitalis stimulates the heart; B, stimulates the vagus centers; C, 
stimulates the peripheral ends of the vagi; D, stimulates the vasomotor center; E, 
stimulates the walls of the bloodvessels. 



The rise of arterial pressure is caused by the increase in pulse-force 
and pulse-volume, and by stimulation of the vasomotor center and 
the muscular coats of the bloodvessels, whereby constriction occurs in 
the walls of the arteries and arterioles. Some recent investigations 
on human beings by means of the sphygmomanometer seem to indicate 
that a rise in pressure often fails to take place, but while this may be 
true in cases in which the pressure is normal or above normal it is not 
true in all cases of low pressure due to ruptured compensation in 
valvular disease. At times the drug may in a case of impaired circu- 
lation lower the pressure, since by improving the circulation in the 
medulla and in the lungs it may cause an increased elimination of 
C0 2 , which in amounts which are not very excessive may raise press- 



DIGITALIS 



259 



ure and so increase the work of the left side of the heart. So too by 
relieving cardiac dyspnea and diminishing labor in breathing it may 
lower a high blood-pressure induced by such vigorous exercise. 

The slow pulse is produced by stimulation of the pneumogastric 
center and the peripheral ends of the vagus nerves and by increasing 
the conduction time over the bundle of His. The increase in the 
volume of the pulse is due to a more complete contraction than 
normal and to the influence on the vagi; for, the pneumogastric nerves 
being stimulated, the diastole of the heart is more full and complete 
and occupies a greater length of time. The result of this delay is that 
the ventricles become thoroughly distended, and on contracting drive 



ii 




in 




IV 



Fig.' 41. — Showing the effect of digitalis on the circulation: I. Before digitalis 
was used: blood-pressure 86, pulse 21 in ten seconds. II. After the use of digitalis: 
blood-pressure 150. pulse 22 in ten seconds. III. Another dose: blood-pressure 164, 
pulse 20. IV. After another dose: blood-pressure 210, pulse 40. 

out a much larger wave of blood through the aorta than is normally 
sent out (Figs. 40 and 41). This is important to remember when 
using the drug in heart disease and other states. 

While it is not known that the vagi are the trophic nerves of the 
heart, there is a large amount of evidence in favor of such a view, and 
it has long been thought that digitalis was not only a heart stimulant, 
but a remedy that increased the growth of its muscular tissue as well. 
If the trophic nerves of the heart are stimulated by digitalis, it 
becomes evident that it is a doubly useful remedy. 1 (See article on 



1 In an original study by the author he found that when digitalis is given con- 
tinuously for a long period of time there results cardiac hypertrophy independently 
of any valvular lesion. See Therapeutic Gazette, December, 1897. 



260 DRUGS 

Heart Disease, in Part IV of this volume, for a further explanation 
of the influence of digitalis in improving the nutrition of the heart 
muscle.) 

When full medicinal doses of digitalis are frequently repeated, or 
when poisonous doses are ingested, the action of the heart may become 
exceedingly irregular. (See Poisoning.) This irregularity may be 
explained as follows: In health the contraction- wave in the heart 
arises in the sino-auricular node, and passes by way of the muscular 
fibers of the bundle of His over the auricles to the auriculo-ventricular 
junction, where it is transmitted by this bundle of His to the ventricles 
in regular sequence. If any cause interferes with the normal trans- 
mission of the contraction-wave from the auricles to the ventricles, 
incoordination between these parts of the heart develops. If a regular 
sino-auricular impulse reaches the ventricle, a normal heart-beat 
occurs, but if it fails to reach the ventricle, this part of the heart does 
not contract, or, if it does contract, it originates its own contraction 
impulse, and, therefore, the ventricular contraction becomes entirely 
independent of auricular contraction, both in its origin and in its 
time, with the result that the ventricle may contract only half the 
number of times per minute that the auricle contracts. 

A toxic amount of digitalis may produce this condition in the 
following manner: Through its influence on the vagi, it distinctly 
interferes with the passage of the contraction-wave over the bundle of 
His, although digitalis does not seem to directly effect this bundle. 
As a result, some or all of the contraction-waves arising at the sino- 
auricular node fail to reach the ventricle and incoordination results. 
Second, the digitalis stimulates the ventricle to increased activity, 
and this aids in the production of extra systoles when the ventricles 
beat independently of the auricles. 1 Auscultation of the heart will 
reveal many beats, some of which are evidently normal, except that 
they may be unduly deliberate. Other beats are abortive, with the 
result that the heart-sounds seem jumbled and irregular as to rhythm 
and force. The radial pulse may be much less frequent than the 
apex beat, because the extrasystoles may not have sufficient blood and 
force to produce a pulse at the wrist. The development of extra- 
systoles or of dropped beats when digitalis is being freely used should 
cause the physician to stop its administration at once. (See Heart 
Disease, and especially Mitral Stenosis.) Sometimes a distinct jugular 
pulse is readily observed which may be synchronous with ventricular 
contraction, because the right ventricle forces the blood backward 
through the right auricle. This irregular pulse, caused by an excess of 
digitalis, is sometimes replaced by an exceedingly rapid pulse, which is 
shuttle-like in character, and, whether the pulse be irregular or rapid, 

1 In some of the earlier editions of this book I have ascribed the irregular action of 
the heart under digitalis to a struggle between its vagus effect and its muscle effect. 
Recently developed knowledge as to His' bundle, as just given, seems to confirm this 
earlier view, now expressed in different terms. 



DIGITALIS 261 

the arterial pressure may be, at this time, low, owing, first to the 
imperfect action of the heart, and, second, to a depression of the vaso- 
motor centers and the muscular coats of the bloodvessels. The rapid 
pulse, when it occurs, is probably due to a depression of the peripheral 
ends of the vagus nerves. 

If a patient who has taken a poisonous dose be suddenly placed in 
an upright posture, death may ensue, owing to the disturbance of the 
contraction- wave in the heart produced by the erect posture. Under 
these circumstances the heart beats so abortively that the circulation 
fails, the condition produced being like that of complete heart-block 
arising from a lesion in His' bundle, as in Stokes-Adams Disease. 

Respiration.— Digitalis has almost no effect on this function unless 
the amount be poisonous, when respiration is slowed. 

Temperature.— Upon the normal bodily temperature digitalis has 
little or no effect in medicinal dose. In poisonous dose it lowers tem- 
perature. In fever the drug seems to cause a slight fall with some 
constancy, but it can rarely be used for any antipyretic influence. 
High temperatures prevent digitalis from slowing the pulse, because, as 
proved by Brunton and Cash, fever depresses the vagus centers in 
the medulla, and also in all probability, when the temperature is very 
high, the peripheral ends of the vagus. This is an important point 
to be remembered in the therapeutic use of this drug. 

Kidneys, Tissue-waste, and Elimination.— Digitalis has almost 
no effect upon the kidney structure itself, and does not to any extent 
stimulate the renal epithelium. The cause of the increased urinary 
flow produced by digitalis in cases of cardiac dropsy depends upon 
the removal of congestion of the kidneys and the increased arterial 
pressure and improved circulation brought about by the drug. 

It is important to remember that digitalis, if given in overdose, may 
cause a spasm of the bloodvessels of the kidney, and so cause sup- 
pression of urine. This is usually accompanied by the development 
of cumulative effects. 

Upon tissue-waste digitalis seems to have little effect, but there is 
still some discrepancy in the reports as to the amount of urea excreted 
under its use, some investigators saying it is increased, others that it 
is diminished. 

It is not known how the drug is eliminated, as chemists have never 
been able to detect it in the urine. It is probably oxidized in the 
body. 

Therapeutics.— Much misunderstanding concerning the action of 
digitalis has arisen, and, while some call it a circulatory stimulant, 
others think it a circulatory depressant. The first class base their 
belief on the signs of increased arterial pressure and cardiac power, 
the others on the fact that it slows and steadies an irritable, rapidly 
acting heart but overlook the other signs. Digitalis is a cardiac 
stimulant and not a sedative, but by regulating its beats it rests the 
heart. If digitalis is used to decrease arterial tension, its dose must 



262 DRUGS 

be dangerously large. (See Heart Disease, Part IV.) Its chief field 
of usefulness is in cases of ruptured compensation in valvular disease 
and in auricular fibrillation. The mere existence of a murmur does 
not indicate its employment. 

Digitalis is of value in nearly all cases of cardiac disease where the 
condition is one in which the heart fails to do its proper amount of 
work unless the failure is due to myocardial degeneration. If simple 
hypertrophy or excessive compensatory hypertrophy exists, it is 
harmful. It is of less value in aortic regurgitation than in any other 
lesion, because the prolongation of diastole allows greater oppor- 
tunity for the blood to fall back into the ventricle, although in the 
second stage of this lesion, when the mitral orifice and valve are 
beginning to be affected, it is often very useful. In some instances 
of mitral regurgitation the drug does harm by overdistending the 
auricle through ventricular stimulation, which results in an increase 
in the regurgitant flow, and we can never tell before trying it which 
cases will be so affected. (See Heart Disease. 1 ) In cases where the 
heart is irritable, palpitation present, and indigestion not the cause of 
the trouble, digitalis is of service. It is also useful in cardiac dilata- 
tion and asthenia, and in that condition which J. M. Da Costa called 
a "tired heart." 

In the second stage of pneumonia if the heart is laboring and unable 
to do its work properly, digitalis is often invaluable (see Pneumonia) . 
In congestion of the lungs in typhoid states it will drive out the blood 
from the part congested and relieve stasis unless the temperature is so 
high that it cannot act or the heart muscle is degenerated. 

In cardiac weakness from collapse, injury, poisoning, or shock digi- 
talis may be used. In aconite poisoning, it is the physiological anti- 
dote. Owing to its tardy action it should, however, be preceded by 
ammonia and strychnine where the need is pressing. In muscarine 
poisoning digitalis and atropine are the antidotes. 

As a diuretic digitalis is most useful when the kidneys are congested 
and the circulation is sluggish from cardiac feebleness. When the 
renal structure is diseased, other drugs should take its place, or it 
should be combined with more active renal remedies, such as squill 
or caffeine, or with compound spirit of juniper in very chronic cases 
of kidney trouble. 

Often when the patient has by error received too much of the 
drug the finger can scarcely note any pulse at the wrist, yet the 
ear when placed over the heart finds it to be beating forcibly but 
abortively. It is important that the weak pulse at the wrist be 
not taken as the only guide as to the state of the patient for this very 
reason, and the physician should always auscult the precordium before 
reaching an opinion as to the action of digitalis. (See Physiological 
Action.) 

1 It is absolutely necessary for the student to turn to the article on Heart Disease, 
and to read it carefully, in order to understand the action of digitalis in disease. 



DIGITALIS 263 

Untoward Effects.— Digitalis sometimes causes nausea and indiges- 
tion by irritating the stomach and if pushed in large doses vomiting. 
In children it is likely to produce marked irregularity of the pulse. 
When given in full doses, the patient should always remain in bed 
and not be allowed to sit up suddenly, as syncope may occur. It 
is particularly important that this rule be enforced if the patient 
desires to empty the bladder, for cases are on record in which a 
patient has risen suddenly, emptied the bladder, and fainted or even 
died in syncope. 

In some cases a cumulative action occurs, which consists in a sudden 
development of the effects of the drug to an excessive degree, so that 
the symptoms resemble those seen after a poisonous dose has been 
taken. This is particularly prone to occur when ascites or dropsy is 
removed by tapping after the drug has been taken for a long period. 
It is thought that the sudden withdrawal of pressure upon the great 
vascular trunks of the body-cavities causes the absorption of the drug 
with the fluids of the tissues where it has remained inactive. Such 
an accident also sometimes occurs when a fever ends by crisis and 
digitalis has been given. It also takes place whenever full doses 
are given so frequently as to be in excess of elimination, for the drug 
is slowly eliminated, and so rapidly accumulates in the body. Cumu- 
lative action is often preceded by a scanty passage of urine. A 
decrease in the quantity of the urine when digitalis is being freely 
used should cause the physician to stop its administration or be 
most cautious in its continuance. 

Poisoning.— The slow, full pulse followed by the hobbling, dicrotic, 
shuttle-like pulse-beats, and the tumultuous cardiac beat, afford a 
combination of symptoms characteristic of the overaction of digi- 
talis. The pulse may be full and slow when the patient is recumbent, 
but at once becomes irregular on his sitting up. 

As the poisoning progresses vomiting may come on, exophthalmos 
occurs, and a peculiar blue pearliness of the sclerotic is seen. Con- 
sciousness is generally preserved nearly to the last. Death from 
digitalis poisoning may not take place for days or may occur in two 
hours or even less. Headache is often a severe symptom. 

Treatment of Poisoning.— Tannic acid is to be given as a chemi- 
cal antidote; emetics and the stomach-pump are to be used, the former 
only when the drug has not been absorbed, for if the heart is much 
affected emetics are dangerous. External heat is to be applied, 
particularly about the abdomen. The maintenance of a horizontal 
position must be insisted upon, for several days after active symp- 
toms have subsided sudden death on sitting up has occurred. The 
use of tincture of aconite, as the physiological antidote, may be 
resorted to. 

Contraindications.— In cases of marked atheroma of the bloodvessels, 
in aneurism and apoplexy digitalis must be used with care because it 
increases circulatory vigor. In fatty degeneration of the heart the 



264 DRUGS 

remaining healthy muscular fibers -of this organ are, it is true, stimu- 
lated by the drug, but it may also increase arterial tension to such 
an extent as to increase the labor of the failing heart. On the other 
hand, by resting the heart, it may do good in many patients, par- 
ticularly if combined with Donovan's solution. 

Administration-.— When digitalis is to be used as a cardiac support- 
ant the physician should pursue a definite plan of action based on 
the knowledge that it is very slow in producing its effects and per- 
sistent when once its influence is established. Even when taken 
into a healthy stomach which is empty it is an hour or two hours 
before its influence is marked and about six to eight hours before 
its effect is at the maximum. At least thirty-six to forty-eight hours 
elapse before the heart may be considered as digitalis-free from one 
large maximum dose. If a heart in an adult is in a bad way as a 
result of decompensation, and no digitalis has been used recently, it is 
often wise to give as much as J to 1 minim of the tincture for each 
pound of the patient's weight, unless the weight is excessive because 
of dropsy. That is, from 1 to 2 drams at the dose and no more for 
twenty-four or forty-eight hours, when the effect may be maintained 
by 15 to to 20 minims (1.0-1.3), three times a day or even less fre- 
quently, care being taken that a toxic effect is not induced. (See 
Heart Disease.) When the electrocardiograph can be used it should 
be employed to gauge the dose (Plate IV). 

It is not to be forgotten, however, that while single doses of 1 
to 2 drams may be remarkably efficient in badly ruptured com- 
pensation, and even more so in auricular fibrillation, they may 
cause death in a case of partial heart block or may induce this state 
if superimposed on large doses recently given. In my opinion a 
massive dose of digitalis should never be employed until by the 
electrocardiograph no contraindications to its use is discovered. 
I appreciate that this puts a limitation on the physician's field of 
endeavor but it is unavoidable. 

The official preparations of digitalis are the tincture (Tinctura 
Digitalis, U. S. and B. P.), dose 5 to 30 minims (0.3-2.0); and 1 to 
3 drams (4.0-12.0) if it is desired to produce a powerful effect as 
soon as possible by a single dose; the infusion (Infusum Digitalis, 
U. S. and B. P.), 1 to 4 drams (4.0-15.0); the fluidextract (Fluid- 
extractum Digitalis, U. S.), dose 1 to 4 minims (0.05-0.25); and the 
powdered digitalis leaves (Digitalis Folia, B. P.), dose \ to 2 grains 
(0.03-0.12), generally given in a pill. It is generally considered 
that 2 grains of the leaves are equivalent to 20 minims of the tincture. 

Some choice should be exercised in the use of the various prepara- 
tions made from digitalis leaves, because the different active ingre- 
dients of the drug possess [different solubilities and exert different 
effects on the circulation. Thus digitalin, digitoxin, and digit alein all 
act as powerful stimulants to the heart muscle. Digitalin also stimu- 



DIGITALIS 265 

lates the vagus peripherally and centrically. All three of these raise 
arterial pressure by stimulating the vasomotor system peripherally 
and centrically. Digitonin, on the other hand, does not stimulate 
the heart muscle, but rather depresses it. It also depresses the vagus, 
and thereby somewhat antagonizes the digitalin, 1 digi toxin, and 
digitalein. 

If we now turn to a consideration of the solubilities of these prin- 
ciples, we can readily explain the different effects produced by the 
infusion and tincture or fluidextract. Digitonin is soluble in water, 
as is digitalein; but digitalin is only slightly soluble and digi toxin is 
scarcely at all soluble in water. As a result, the use of the infusion 
in a case of heart disease would not give the patient the same degree 
of cardiac power as the use of the tincture, for not only would the 
most powerful stimulant of all to the heart, vasomotor system, and 
vagi— namely, digitalin— be present in small amount, but in addi- 
tion the large proportion of digitonin would antidote it. On the 
other hand, digitonin is sparingly soluble in alcohol, while digitalin 
and digitalein are readily soluble in it, digi toxin being slightly so. 
It would seem, therefore, that in the presence of a failing heart and 
circulation the tincture and the fluidextract are the preparations 
greatly to be preferred to the infusion, because they contain large 
amounts of the active stimulant ingredients. 

The reason that the infusion acts efficiently as a diuretic in some 
cases probably depends upon the fact that as it does not contain so 
much digitalin it is less apt to cause spasm of the renal vessels; but 
if the heart is feeble and there is renal stasis, the tincture is probably 
the better preparation to overcome this state, because it both aids 
the heart and by contracting the renal vessels overcomes the stasis. 
The use of digitalin is inadvisable unless we are sure that we get that 
made according to the process of Schmiedeberg, for the other digi- 
talins usually sold are very uncertain. The infusion is far more 
apt to disorder the stomach than the fluidextract or tincture, because 
of the irritating digitonin. The dose of digitalin, which ought not to 
be used as a substitute for digitalis, is -^ grain (0.001). There is, 
however, a great difference of opinion as to the correct dose. Some 
men give as much as 1 grain; and the French pharmacists state the 
dose of Nativelle's digitaline should be only ^Ito grain. 

Much confusion exists as to the names applied to the various 
derivatives of digitalis. There appear to be no less than four distinct 
substances upon the market called "digitalin," and they differ greatly 
in power. Thus, " German crystalline digitalin" is really digitonin, 
that is, a saponin. French crystalline digitalin is digitoxin and 
corresponds to Nativelle's digitalin. French amorphous digitalin 

1 By digitalin, reference is made to that prepared by Merck, and sometimes called 
the digitalin of Schmiedeberg, and not the amorphous form of Homolle nor the crystal- 
line digitalin of Nativelle. 



266 DRUGS 

purum is seemingly a mixture of digitalin and digitoxin and equals 
Homolle's digitalin. German amorphous digitalin purum is a mixt- 
ure of true digitalin and digitalein with 50 per cent, of amorphous 
digitonin. Digalen (dose of solution 1 to 2 cc) is said by Kobert 
to be a solution of digitalein in water, but Cloetta thought it to be 
soluble digitoxin. Digipuratum (dose 1J grains (0.1) or in liquid 
form 1 cc), according to Grier, is a mixture of digitoxin and digi- 
talin, and is said to be of the same strength as the leaves, grain for 
grain. All these facts indicate pretty clearly that the physician 
should use none of these products, but rely on galenical preparations 
of digitalis leaves. 

When digitalis cannot be given by the mouth there is little use in 
giving any of the official preparations hypodermically, for they are 
precipitated in the tissues. Absorption of digitalis may be brought 
about by the use of a poultice made by placing some digitalis leaves in 
a small bag and steeping them in hot water. The bag is then placed 
over the loins. This plan of treatment must be cautiously employed 
to avoid poisoning, because one cannot tell how much digitalis is 
being absorbed. 

Under the name of "Digitalone," Houghton has devised an excel- 
lent preparation of digitalis, now on the market, suitable for use by 
mouth or hypodermic needle, since it represents the full therapeutic 
value of the drug, and is readily absorbed with little irritation when 
given hypodermically, which is not true of tincture of digitalis. This 
product is "fat-free," and is standardized by well-recognized pharma- 
cological tests upon the lower animals. 

Digitalone is put up in hypodermic tablets of j 3 ^ grain (0.0065), 
corresponding to about 3 minims of tincture of digitalis and J grain 
(0.03), corresponding to about 16 minims of tincture of digitalis. 
It also appears in ampoules equal to 16 minims (1.0) of the tincture 
and in tablet triturates of | grain (0.012). 

Under the name "Digifoline," a Swiss chemical firm markets a prepa- 
ration which is said to contain all the active ingredients of the leaf 
with all of its useful parts. It is physiologically standardized. It 
appears in tablets and in liquid form in ampoules, the contents of 
which represent If grains of digitalis leaf. The ampoules are intended 
for hypodermic therapy. It is somewhat irritating. 

Attention has already been called to the necessity of using a prepa- 
ration which has been subjected to a physiological test by the manu- 
facturer before it is placed on the market. This is important because 
the crude drug varies so greatly in strength that even the most careful 
pharmacist cannot be sure that each lot of leaves is of equal medicinal 
strength, and chemical analysis of their complex make-up is practi- 
cally impossible. Often when a patient has been taking an ordinary 
preparation of digitalis without good results the writer has seen the 
use of a physiologically tested and active preparation do much good. 



DUBOISINE 267 



DIONIN. 



Dionin, or Mthylmorphinaz Hydrochloridum, U. S., is an artificial 
product derived from morphine, and occurs as a white crystalline, 
faintly bitter powder. It is soluble in about 8 parts of water, 20 of 
alcohol, and slightly soluble in ether and chloroform. 

Dionin is used for several purposes in medicine, both internally 
and externally. Internally it is employed in the dose of J or f grain 
(0.015-0.045) to relieve excessive cough and pain in the chest, in various 
forms of pulmonary disease. It has also been used as a substitute for 
morphine in various painful affections of the internal viscera, as in 
ulcer and cancer of the stomach and bowel, in cases in which morphine 
cannot be used because of nausea. It is said to be equally efficient 
with morphine in the relief of pain but less powerful for the purpose 
of producing sleep. It may also be given to fortify barbital and 
sulphonal in cases of insomnia. In the dose of 1 grain (0.06) dionin 
may be used in suppository in painful conditions of the rectum. 

Externally dionin finds its chief use in the eye. It has been found 
especially valuable in certain types of ulcerative and parenchymatous 
keratitis, iridocyclitis, and glaucoma when used in solutions varying 
from 1 to 5 per cent. This solution is dropped into the conjunctival 
sac two or three times a day. At first it causes a sharp reaction 
with a sense of burning and marked edema of the conjunctiva, which, 
however, subsides in about twenty minutes, and analgesia, not 
anesthesia, develops. That is, it relieves pain, but does not locally 
anesthetize, as does cocaine. When it is used mixed with cocaine, 
both an anesthetic and analgesic effect is obtained. Immunity to its 
irritant effects is so soon established that its use on subsequent days 
causes little or no irritation. 

If the patient is hypersensitive, the primary painfulness of dionin 
may be prevented by preceding its use by cocaine solution. It is 
also advisable to drop the dionin solutions into the conjunctival sac 
so as to avoid the cornea, which is much more sensitive to its effects 
than the conjunctiva. Dionin may be added to solutions of myotics 
or mydriatics when it is desired to relieve eye pain at the same time 
that the beneficial effects of the other drug are obtained. 

DIURETIN. 

(See SODIO-SALICYLATE OF THEOBROMINE.) 

DUBOISINE. 

Duboisine is the alkaloid of the leaves of Duboisia myoporoides, a 
plant of Australia. The crude drug is little used in medicine, but 
duboisine sulphate is used as a mydriatic under the same conditions as 
is atropine, and more largely still as a hypnotic in insanity, inter- 
changeably with hyoscine. The dose of duboisine sulphate hypoder- 
mically as a hypnotic is ■£$ to -gV grain (0.0008-0.001).- The clinical 



268 DRUGS 

experience so far adduced would seem to indicate that it tends to 
decrease urinary secretion and to disorder the digestion, producing at 
the same time a soapy taste in the mouth, with excessive dryness 
of the mucous membranes. Rarely it causes profuse salivation or 
sweating in those who have an idiosyncrasy to its use. In a large 
number of insane and hysterical cases de Montyel found its use was 
followed by vomiting of part of the food, but the patients seemed to 
have no nausea. The sulphate has been used with much asserted 
success in the treatment of paralysis agitans. Usually the dose by 
the mouth for this purpose has been T ^ grain three times a day. 
Cividati and Gianelli assert that duboisine is useful in epilepsy, par- 
ticularly in its psychic forms. 

ELATERIUM. 

Elaterium, B. P., is a sediment obtained from the juice of Ecballium 
elaterium, or squirting cucumber. It appears in small, friable, thin, 
grayish-green flakes, having a bitter taste. Elaterium is not official 
in the U. S. P., but its active principle, elaterin (Elaterinum, U. S. 
and B. P.), is official. Elaterin is a neutral principle deposited by 
the juice. Notwithstanding this fact, the crude drug is largely used. 

Physiological Action.— Elaterium is a decided irritant to all mucous 
membranes, and even to the fingers of those who handle it. Its chief 
effect when taken internally by man is to cause profuse water stools, 
but for some unknown reason it rarely acts upon animals in this 
manner. 

Therapeutics.— This drug is the best hydragogue purge which we 
have, causing large watery passages, but not producing much pain 
when used in proper dose. For this reason it is useful in the treat- 
ment of local serous transudations. In serous effusions due to acute 
or chronic inflammatory processes it is of little value because in such 
cases the stomata of the serous membranes involved are closed by 
fibrin, as in pericarditis and pleurisy. In dropsy and ascites or gen- 
eral anasarca it may be useful. It ought never to be used in cases 
of marked exhaustion, and may be advantageously followed, soon 
after it acts, by alcoholic stimulants. In uremia with dropsy it is 
thought to aid in the elimination of the uremic poison by the bowel. 
In cerebral congestions or effusions the drug is of service by depleting 
the diseased vessels. 

In poisoning by elaterium the symptoms are those of violent 
gastro-enteritis, and must be treated accordingly. (See Gastro- 
enteritis.) 

Administration.— The dose of elaterium is £ grain (0,01), given in 
freshly made pill. Elaterin is best given in the dose of from 2V to 
^ grain (0.003-0.006), as follows: 

1$ — Elaterini gr. iv (0.25) 

Alcoholis f§iv (120.0).— M. 

Dissolve by gentle heat. 

S. — Half a dram contains ^ grain (0.004), or one full dose. 



ERGOT 



269 



The official preparation of elaterin, the active principle of elaterium 
is Trituratio Elaterini, U. S. (elaterin 1, sugar of milk 9), given in the 
dose of i to 1 grain (0.03-0.06). Pubis Elaterini Compositus, B. P. 
(elaterin 1, sugar of milk 39), is given in the dose of 1 to 5 grains 
(0.06-0.3). 

ERGOT. 

Ergota, U. S. and B. P., is derived from the spawn or mycelium of 
the fungus known as Claviceps purpurea, which grows in the flower 
and replaces the grain in common rye, or Secale cereale. After being 
kept for a year crude ergot is not fit for use. 

Many so-called active principles of ergot 
have been isolated by chemists, and named 
ecbolic acid, ergotic acid, sclerotinic acid, and 
ergo tin. None of these represent the entire 
drug. One active constituent is ergotoxin, 
which is an amorphous alkaloid and is prob- 
ably the chief agent in the effect of ergot on 
the uterus and bloodvessels. Another ingre- 
dient is tyramine, which raises blood-pressure 
by a tonic effect on the bloodvessels but does 
not affect the uterus. Histamine is also pres- 
ent, and this ingredient, although an active 
uterine stimulant, lowers blood-pressure 
markedly. 

Physiological Action.— Nervous Systom.— 
Upon the nervous system ergot exercises 
little, if any, effect. 

Circulation.— Ergot, when injected into 
the circulation causes a primary fall of arter- 
ial pressure, followed by a slight rise. This 
rise is probably due to a stimulation of the 
muscular coats of the bloodvessels, but the 
primary fall is caused by its direct depressant 
effect upon the heart muscle, resulting from 

the direct contact of the drug en masse with the heart. If the dose 
be very large, and the fall of pressure is not recovered from, progres- 
sive paralysis of the vasomotor apparatus and heart occurs. When 
given in medicinal doses by the stomach the drug causes a slight rise 
of arterial pressure, chiefly by an action on the heart and the mus- 
cular coats of the bloodvessels, but this effect would seem to be too 
feeble to be of much value in bedside practice. 

Uterus and Unstriped Muscular Fiber.— It has been com- 
monly taught that the contractions of the uterus produced by 
medicinal doses of ergot are due to the stimulating influence of this 
drug upon the muscular fibers of this organ ; but Dale seems to have 
proved that the influence is exercised on the nerve-endings in the 




Fig. 42. — A, ergot stim- 
ulates the uterine centers 
in the spinal cord, and B, 
the muscular fibers in the 
uterus itself. 



270 DRUGS 

muscles. It is also a fact, as shown by the careful studies of Hem- 
meter, that the drug causes uterine contractions by stimulating the 
centers in the lumbar portion of the spinal cord which controls this 
viscus. 

On the uterus ergot in full medicinal dose exerts its influence not by 
increasing the normal pains of labor, but by causing a tetanic, tonic, 
unyielding uterine spasm which drives all before it. In very small 
doses it may assist the normal contractions without causing them 
to become tetanic. 

Ergot acts as a stimulant to all unstriped muscular fibers. 

Acute Poisoning.— The symptoms of overdosing from ergot, when 
the effects are slowly produced, are sometimes great hunger or craving 
of food, at other times nausea and vomiting. If the poisoning is 
quite severe, there are great restlessness, headache, delirium, and 
coldness of the surface of the body. 

Chronic Poisoning.— Two forms of poison from the prolonged use 
of ergotized rye bread sometimes occur. One is characterized by 
spasmodic muscular contractions, the other consists in the formation 
of gangrenous sloughs. In the first of these forms it is not very 
uncommon for cataract to develop, and it is stated that the spasms 
are due to the influence of one of the principles of ergot— namely, 
cornutine. 

Therapeutics.— Ergot is given to parturient women for the preven- 
tion or arrest of post-partum hemorrhages. For the prevention it 
should be given to the woman by the mouth after the delivery of 
the head, but in many instances its use is needless. When admin- 
istered to check a hemorrhage already flowing, the doses should 
be large, as much as 1 to 2 drams (4.0-8.0) of the fluidextract or 
1 wineglassful (30.0) of the wine of ergot. The drug should produce 
its effects in about fifteen minutes, and may be repeated every 
fifteen minutes until it acts. The action lasts about half an hour. 
Ergot should not be given in the early stages of labor, but this rule 
may, under certain conditions, be modified. If uterine inertia comes 
on in the course of a normal labor, which cannot be overcome by the 
use of coffee or strychnine, or other nerve-stimulant, a small dose 
of ergot may be employed. Such small dose does not cause a con- 
stant tetanic uterine contraction, but simply brings on the " to-and- 
fro" movements. By a "small dose" the writer means from 5 to 20 
minims (0.3-1.3) of the fluidextract. Caution must be used even 
with this dose. 

If the birth-canal is obstructed, ergot should never be employed, 
and, unless the os uteri is well dilated, it should not be given in any 
dose. 

In postpartum hemorrhage it is well to give "Ergot Aseptic" or 
"Ergone" hypodermically. "Ergot Aseptic" is dispensed in sealed 
and sterile glass ampoules, and is a concentrated preparation of ergot 
intended for hypodermic use. Each bulb holds one dose, and the 



ERGOT 271 

drug is drawn directly from it into the syringe. This is a most useful 
preparation, physiologically tested and twice as strong as the fluid- 
extract, U. S. P. 

When ergot is given, care should be taken that the uterine cavity 
is free from all clots or placental fragments, lest closure of the os 
uteri under the influence of the drug imprison these harmful materials. 

According to many obstetricians, whose results have been confirmed 
by a number of special studies, ergot in moderate doses very distinctly 
aids in overcoming subinvolution of the uterus. 

In hemorrhages from the lungs and kidneys or other unapproachable 
parts ergot is thought by some to be very useful when given by the 
mouth, but it is probable that it rarely achieves any good. Par- 
ticularly is this the case in pulmonary hemorrhage, since a vaso- 
motor system practically does not exist in the pulmonary vessels, and 
the increased pressure caused by the ergot in the general systemic 
circulation may increase the pulmonary leakage. The truth is, that 
in pulmonary hemorrhage little real good can be obtained by the 
use of vasoconstrictors. 

In epistaxis, menorrhagia, and metrorrhagia, and in some cases of 
night-sweats, ergot is of service. In hypostatic, pulmonary, and other 
congestions it is useful, particularly if used with digitalis. In dysen- 
teries with bloody stools and in serous diarrhea ergot sometimes does 
good. 

Some persons suffer from vertigo associated with hyperesthesia of 
the scalp and headache. Relief can often be obtained in such cases 
by the use of 20 minims (1.3) of the fluidextract of ergot and 5 to 10 
grains (0.3-0.6) of bromide of sodium three times a day. 

Ergot has been used very largely in the treatment of uterine fibroids 
as an expulsive remedy and cure. It is only of value in those cases 
where the growths are just beneath the mucous membrane. By the 
contractions of the uterine muscular fibers the blood-supply of the 
growth is decreased, the recurring hemorrhages cease, and the tumor 
is finally expelled, having sloughed out of its bed. This method is 
far inferior to the knife, and very painful and prolonged. Large 
growths cannot be so treated. Ergot is sometimes useful in the 
treatment of bleeding hemorrhoids, and in diabetes insipidus, in which 
disease it is well to combine with it the bromide of sodium. 

Administration.— Ergot is official as the fluidextract (Fluidextractum 
Ergota, U. S.; Extractum Ergota Liquidum, B. P.), dose J to 1 dram 
(2.0-4.0), 10 to 30 minims (0.6-2.0), B. P.; and the extract {Extractum 
Ergotce, U. S. and B. P.), dose 5 to 30 grains (0.3-2.0), 2 to 8 grains 
(0.12-0.48), B. P. Bonjean's ergotin is made by a special process, 
and it can be given hypodermically if "Ergot Aseptic" or "Ergone" 
cannot be had. The B. P. preparations are Infusum Ergots, 1 to 2 
fluidounces (30.0-60.0), and Injectio Ergotw Hypodermica, B. P., 
given in the dose of 3 to 10 minims (0.2-0.6) by subcutaneous injec- 
tion. The B. P. also recognizes an ammoniated tincture of ergot 



272 DRUGS 

(Tindura Ergotce Ammoniata). Ergotin (Ergotinum) is given in the 
dose of 2 to 5 grains (0.12-0.3). 

As ergot is a drug that varies greatly in physiological activity in 
its crude state, and cannot be chemically assayed with advantage, the 
physician should always use a preparation which has been physiologi- 
cally tested by the manufacturer before it is placed on the market. 
This may be done by studying its effect on the uterus of a pregnant 
animal, or by giving it to animals and observing its effect on the caliber 
of the small vessels. If the drug is active, it causes stimulation of the 
muscular coats of the vessels; and if its use is persisted in, it finally 
occludes them. Houghton has shown that an active ergot will cause 
gangrene of the rooster's comb if it is given constantly. Inert ergot 
will not do this. Much credit is due to Houghton for having perfected 
this valuable pharmacological test. 

The younger Wood asserts that the fluidextract loses 10 per cent, a 
month in strength even when it is kept hermetically sealed in a bottle. 
A fresh preparation is therefore essential. 

The active principle tyramine may be given as an active vascular 
stimulant in the dose of yo grain (0.006) hypodermically. It has 
usually failed in my hands. 

ERIGERON, OR FLEABANE. 

Oil of erigeron is a yellowish volatile oil of a peculiar, not un- 
pleasant, taste, closely resembling that of turpentine, which is 
distilled from the fresh flowering herb of Erigeron canadense. It may 
used as a remedy for the treatment of passive uterine oozing, or a 
"show," as it is sometimes called. In epistaxis and other hemor- 
rhages of moderate degree it is useful. In some instances it is used 
in place of copaiba and cubebs in the later stages of gonorrhea. It 
is best given in capsule or on sugar in the dose of 10 to 30 minims 
(0.6-2.0) after meals, or oftener if needed. 

ERYTHROL TETRANITRATE. 

(See article on Nitkoglycekin.) 

ETHER. 1 

Sulphuric ether is official as Mther, U. S., and Miher Purificatus, 
B. P., and in the U. S. Pharmacopoeia of 1880 was called Mther 
Fortior. It is a liquid composed of about 96 per cent., by weight, 
of absolute ether or ethyl oxide, and about 4 per cent, of alcohol 
containing a little water. It should be kept in partially filled, well- 
stoppered containers, preferably tin cans, in a cool place, remote 
from lights or fire. It is a transparent, colorless, mobile liquid hav- 

1 The student should read the article on Chloroform in conjunction with this article. 



ETHER 273 

ing a characteristic odor, and a burning and sweetish taste, and is 
soluble in about 12 times its volume of water at 25° C. (77° F.), 
with slight contraction of volume. It is miscible in all proportions 
with alcohol, chloroform, petroleum benzin, benzene, fixed and 
volatile oils. Ether boils at about 35° C. (96° F.), and it should, 
therefore, boil when a test-tube containing some broken glass and 
half filled with it, is held for some time closely grasped in the hand. 

Ether is made by the action of sulphuric acid on ethylic alcohol. 

It is highly volatile and inflammable. Its vapor, when mixed with 
air and ignited, explodes violently. The color of light blue litmus 
paper moistened with water should not be changed to red when the 
paper is immersed in ether for ten minutes. Upon evaporation, 
ether should leave no residue. If 10 cc of it be poured, in portions, 
upon clean odorless blotting paper, and allowed to evaporate spon- 
taneously, no foreign odor should be perceptible when the last trace 
of ether leaves the paper. 

Ordinary ether is not used as an anesthetic, but for the abstraction 
of oils and for other pharmaceutical purposes. It contains about 74 
per cent, of ethyl oxide and 16 per cent, of alcohol, with a little water. 

Owing to its inflammable nature ether should never be held near a 
fire or light, and, as its vapor is heavier than air, any flame in the 
room should be above the patient, not below him. No flame should 
be held nearer to the ether than five feet. 

Physiological Action.— The action of ether on the animal organism 
when its vapor is inhaled is very rapid and powerful, but fleeting. 
When applied to the skin it causes intense cold if allowed to rapidly 
evaporate, and may be used in the form of a spray to benumb sensa- 
tion. 

The passage of ether vapor into the blood by way of the lungs 
depends upon the law governing the partial tension of gases. If the 
air in the alveoli of the lungs contains a given per cent, by volume of 
ether, there will be a tendency for the blood in the bloodvessels of 
those alveoli to take up this vapor until the percentage is the same 
in the blood as it is in the air of the alveoli. If, on the other hand, 
the blood contains more ether vapor than the air, the vapor will tend 
to pass from the bloodvessels to the alveoli. This explains why it 
is that in accidents during ether anesthesia artificial respiration, by 
forcing out the ether-laden air of the alveoli, aids the blood in getting 
rid of poisonous amounts of the drug and so directly tends to restore 
the patient. 

Upon mucous membranes ether as a liquid or in vapor acts as an 
irritant, and causes, when its concentrated vapor is first inhaled, great 
irritation of the fauces and respiratory tract, so that temporary 
arrest of respiration is not uncommon. The face becomes suffused 
and red and the conjunctiva injected. Owing to these conditions 
the patient often is restless or struggles to move his face away from 
the vapor, but a stage of quiet soon succeeds this primary stage of 
18 



274 



DRUGS 



struggling. During this period of quiet the breathing is generally 
full and deep and the pulse rapid but strong, while the ocular reflexes 
are at its beginning intact. Following this stage a second period of 
restlessness or struggling may come on, in which the patient becomes 
absolutely uncontrollable except by brute force. Yelling, shouting, 
cursing, or laughing and crying, may be prominent symptoms, and 
the individual is pugilistic, caressing, or ill-tempered, according to 
his temperament. All these disagreeable symptoms can usually be 
avoided if the drug is gently and skilfully given. If the drug is 
now pushed a condition of total unconsciousness and anesthesia is 
soon attained, and quietude takes the place of the struggles. This 
is the time for the operation to be carried on, for if it is attempted 





Fig. 43. — Ether produces anesthesia by depressing the perceptive areas in the 
brain, A. Later it depresses the intellectual areas, B, and the motor areas, C. After 
this the sensory paths in the spinal cord are depressed, D, and finally the motor tracts 
in the cord, E. 



in the earlier stages the struggles of the second stage prevent any 
operative procedures. (See Therapeutics, below.) It is not proper 
to push the drug until the muscular relaxation amounts to complete 
flaccidity, as this endangers the respiration. 

Nekvous System.— In producing its effects, ether acts first on 
the brain, then on the sensory tracts of the spinal cord, then on the 
motor tracts, then on the sensory side of the medulla oblongata, and 
finally upon the motor side of the medulla, and thereby produces 
death from respiratory failure if given to excess. Upon the nerve 
trunks it exerts no effect unless it is directly applied to them. Ether 
does not produce anesthesia by influencing the blood, coagulating the 
protoplasm of the nervous system, or by any other destructive 
influence. It simply inhibits, for the time being, the vital functions 



ETHER 275 

of the parts affected by it. The anesthesia from ether develops 
when ether vapor is present in the blood-serum in the proportion 
of 1 to 400. (See Chloroform.) 

Circulation. —Ether is one of the most diffusible and rapidly 
acting cardiac stimulants which we possess, and is correspondingly 
fleeting in its effects. It increases the pulse-rate and force by stimu- 
lating the heart and the arterial pressure by increasing the activity 
of the vasomotor centers. This statement has been contradicted by 
laboratory investigators, who claim that ether is never a cardiac 
stimulant in a strict technical sense. However this may be, ether 
is used and acts as a most useful circulatory stimulant in man when 
it is given by the mouth and when inhaled in small amounts. In 
overdoses it acts as a cardiac depressant, but only when the amount 
is very large. Upon the blood, the author's colleague, J. Chalmers 
Da Costa, has shown that ether, when given by inhalation, decreases 
the hemoglobin richness of each corpuscle, although there is an 
apparent increase in the number of the corpuscles themselves, par- 
ticularly in those persons who are already somewhat anemic. 

Respiration.— As already stated, when ether is first inhaled in 
concentrated form it often causes arrest of respiration. According 
to Kretzschmar, this is due to an irritation of the trifacial nerve, 
which causes a reflex spasm of the glottis, and not to irritation of 
the peripheral vagi in the lungs. This is only partly true, for the 
author has proved that section of the vagus nerves prevents this 
occurrence, so that both the vagal and trigeminal irritations are 
responsible for the arrest. 

In patients under ether the movement of the diaphragm is an 
exceedingly interesting study, for before the condition known as 
surgical anesthesia is developed, while there is still some rigidity 
and the throat reflex is not completely abolished, the contractions 
of the diaphragm are frequently so violent that unless the laryngeal 
opening be absolutely free the intercostal spaces are depressed and 
the abdominal contents thrust violently downward and outward. 
Just so soon, however, as the chin is pulled forward and a free access 
of air is allowed, the abdominal displacement, though it is still present, 
is not so great, and the chest movement is no longer reversed. As 
the ether is pushed the respiration becomes purely thoracic, the 
diaphragm no longer taking part in the respiratory cycle, or becom- 
ing so relaxed that it allows the chest on expansion to aspirate the 
abdominal viscera upward, as is shown by the retraction of the 
belly-walls at a time when they should normally expand with the 
thorax in inspiration. This observation would seem to point to 
the fact that the primary stimulant action of ether upon the respira- 
tory apparatus is particularly felt by those centers which govern 
the movements of the diaphragm, and that, as this is the case, these 
centers later are the first to feel the paralyzing effect of still larger 
amounts of the drug. 



276 DRUGS 

These facts give us, therefore, a danger-signal during the adminis- 
tration of ether, and the integrity of the diaphragmatic function, as 
represented by the movement of the belly-walls, should be as care- 
fully observed as are the thoracic excursions, the character of the 
pulse, or the condition of the pupil. The rule may therefore be laid 
down that when the diaphragm ceases to act, anesthesia has been 
carried to its extreme legitimate limit, and that the use of an anes- 
thetic after this time must be carried on with the greatest care and 
watchfulness. 

The diaphragm is the first part of the respiratory mechanism to 
yield to respiratory paralysis. In death from any cause the progress 
of failure of respiration will, in the vast majority of cases, be denoted 
by a failure on the part of the diaphragm primarily, with compensa- 
tory excursions of the chest; and it is also to be noted that as the chest 
movements fail the accessory muscles of the neck come into play. 
These muscles in time cease to act, the hyoidean group lose their point 
d'appui, the chest remains motionless, the lower jaw is dropped, and 
the scene is closed by a few gasps in which the muscles of the neck 
may be the chief factors. 

Upon the respiratory center ether acts as a powerful stimulant when 
used in ordinary amounts; in overdose it paralyzes this part of the 
nervous system. 

Temperature.— Prolonged etherization lowers the bodily heat 
very greatly. That of the dog may be lowered some 9° F. in an 
hour if the drug be pushed, and as great a fall has been known as 
4° F. in man. The fall is partly due to the depression of the nervous 
system and the chilling of the body and lungs by the evaporation 
of the drug. 

Elimination.— Ether escapes from the body by the lungs and 
kidneys, chiefly by the lungs. 

Untoward Effects.— Ether, while safer than chloroform, is not abso- 
lutely devoid of dangerous effects. 1 Sometimes, when the drug is 
pushed too strongly, deep cyanosis with pulsation of the jugular 
veins shows deficient oxygenation of the blood and cardiac disten- 
tion. In other, very rare, instances sudden cardiac failure has 
occurred or total arrest of respiration ensued. In nearly all cases 
of sudden death from ether grave kidney or heart lesions have been 
found at the autopsy. Rarely the rise of arterial pressure which it 
produces has caused apoplexy. 

The treatment of accidents during etherization consists in the 
withdrawal of the ether, the use of artificial respiration, and the 
placing of the body, if the face is pale, head downward. On the other 
hand, if the face is flushed and cyanotic it indicates respiratory, not 
cardiac, failure, and this position is not to be resorted to. The 

1 The mortality due to etherization is about 1 in 20,000! or, according to the com- 
bined statistics of Julliard and Ormsby, in 407,553 cases there were 25 deaths, or 1 in 
16,302. (Compare Chloroform.) 



ETHER 



277 



physician should also employ hypodermic injections of strychnine, 
atropine, and digitalone, or more rarely, an intravenous injection of 
ammonia, which is more dangerous, but better than the others in 
a pressing emergency because it is more rapid in its action. Ether 
is often given hypodermically under such circumstances, and may 
occasionally do good; but its use is a bad practice, for if the heart 
or respiration is already depressed by ether, the employment of 
still more of the drug simply makes matters worse. The cases in 
which such a line of treatment is followed by good results are those 




Fig. 44. — Illustrating how traction on the tip of the tongue draws the epiglottis 
away from the glottic opening and permits free ingress of air. Also showing how 
letting the tongue fall back in the mouth in anesthesia would close the air passages 
and permit the epiglottis to interfere with breathing. (This is important.) For a 
full description see article on Asphyxia. (From a research by Martin and the author.) 

in which the failure of respiration is not due to a saturation of the 
body with ether, but to asphyxia produced by mechanical interfer- 
ence with free breathing, as, for example, the presence of mucus 
in the air-passages or a too close application of the inhaler to the 
face. In such cases the hypodermic injection of ether causes so 
much local pain and irritation as reflexly to excite respiratory move- 
ments, as well as to stimulate directly the respiratory center to 
greater effort. 1 Alcohol ought not to be used if the other drugs 

1 As consciousness is not necessary to the carrying out of a reflex action, this is 
perfectly possible and probable. 



278 DRUGS 

named can be obtained, because alcohol is so nearly allied physio- 
logically and chemically to ether. Frictions, hot applications, and 
artificial respiration should be practised. (See article on Asphyxia.) 

The diaphragm being the most important muscle of respiration, 
the physician should seek to stimulate it by resorting to Laborde's 
rhythmic traction of the tongue, which consists in rhythmically 
drawing the organ outward and upward from the mouth ten to 
fourteen times a minute. 

As ether is at hand, it may be dashed on the chest and abdomen, 
to cause inspiration by reflex action, in lieu of cold water, which 
wets the clothes and does not evaporate rapidly. 

In about 30 to 40 per cent, of cases nausea and vomiting follow 
the use of ether. This can generally be prevented by the avoidance 
of food for twelve hours before an operation, and by the adminis- 
tration of cracked ice and small doses of acetanilid and brandy after 
the operation. (See Vomiting.) This condition may also be avoided 
in many cases by giving oxygen gas with the anesthetic or by induc- 
ing anesthesia rapidly by means of nitrous oxide and following it 
with ether. (See Oxygen, Important.) Severe bronchitis may occur 
in invalids and children after the inhalation of ether, and in many 
cases this is due more to exposure than to the drug. Pulmonary 
complications, while possibly due to the direct effect of the ether, 
are probably chiefly the result of the inspiration of particles of food, 
foul secretions from the mouth, and perhaps blood, into the lungs, 
the glottis being anesthetized and unable to protect the lungs from 
the invasion of foreign matter. Great cleanliness of the mouth is 
essential before every operation, and care should be taken during 
and after an operation that septic materials are not inspirated. It 
is wise to order a peroxide of hydrogen mouth-wash beforehand. 

Total or partial anuria may develop after etherization, particularly 
after abdominal operations. This is a very dangerous symptom, 
which can sometimes be removed by giving nitroglycerin, to relax 
spasm of the renal vessels, and a large rectal injection of normal saline 
solution. It has, however, been proved, both experimentally and 
clinically, that ether is not capable, in the ordinary patient, of pro- 
ducing renal disorder of any moment unless the kidneys are already 
diseased or the patient is soaked with the drug, as sometimes occurs 
when it is improperly given. Weil asserts that ether is not danger- 
ous even in those with moderately diseased kidneys but in a goodly 
proportion of cases the use of ether diminishes urinary flow and 
decreases the escape of solids even more than it decreases the elimina- 
tion of liquids. The employment of ether in diabetic patients is 
dangerous; the patient often never regains consciousness after its use. 
Postanesthetic toxemia may arise after the use of ether. Cases have 
been reported by Brachett, Stone, Low and others. (See Chloroform 
for Postanesthetic Toxemia.) 

Sometimes after the use of ether in the case of an old person or 



ETHER 



279 



a child the bronchial tubes so fill with mucus that there is danger of 
the patient drowning in his own secretions. A full dose of atropine, 
which checks secretion, given hypodermically, is useful at such times, 
and may be used beforehand as a prophylactic. 

Sometimes after an anesthetic is given the patient is found to have 
a monoplegia. This is not due to the anesthetic, but to pressure 
exercised upon the nerve supplying the part during the anesthesia. 
It is a true pressure-palsy. 

Administration.— In giving an anesthetic it is of the greatest import- 
ance that the patient shall not be frightened or made nervous by its 
too free use at first, and it is better in nervous women and children 
to produce anesthesia while they still remain in bed, so that the sight 
of the operating-room will not disturb them. By this means not 
only nervous strain is avoided, but fearful " nightmares" while under 
the effects of the drug are prevented. The greatest gentleness 
should be exercised and the mind diverted, if possible, by some 
pleasant thoughts. 





Fig. 45. — Allis inhaler. 



Fig. 46. — Safety-pin to make ether- 
dropper out of ordinary can. 



In all persons it is a mistake to have the shoulders and head rest- 
ing on the same plane as the body, particularly in adults and in the 
obese. This flatness is constantly practised. Let him who doubts 
its disadvantage attempt to lie on a flat hard surface and he will be 
conscious of difficulty in respiration. 

Ether is used chiefly as an anesthetic by means of inhalation. 

The best plan of administration is by the so-called "drop method." 
This consists in using an Esmarch inhaler (see Chloroform), and 
allowing the ether to fall drop by drop upon its surface in the same 
manner that chloroform is used, but somewhat more freely. By 
this means^ the patient escapes disagreeable oppressive sensations 
at the beginning of the administration and, more important, the 
nausea and vomiting during and after anesthesia are greatly dimin- 
ished as to frequency of occurrence and severity, as is also the danger 



280 DRUGS 

of renal and respiratory irritation and post-anesthetic toxemia. In 
other words, the patient is not in danger of being poisoned by an excess 
of the drug, but is kept under its effects only sufficiently to avoid 
pain, restlessness, and voluntary movement. The disadvantages of 
this plan are that it takes longer to anesthetize the patient, uses 
more ether, and is often not adequate in those addicted to narcotics 
or for powerful men. It is, however, peculiarly suitable to women 
and children. The use of an "Allis inhaler" (Fig. 45) enables us to 
use the "drop method" in the more resistant patients because larger 
amounts of ether can be given and yet the patient receives plenty 
of air. There is no justification in giving the ether so freely as to 
cause a sense of suffocation and fear. The better way is to hold the 
inhaler at some distance from the face, and gradually bring it nearer 
as the effects of the ether are developed. As the vapor of ether is 
heavier than air, it falls over the patient's face in concentrated form, 
even if the distance between the inhaler and the patient amount to 
several inches. There is, therefore, no justification in applying the 
cone to the face at the very beginning of the inhalation. After 
partial anesthesia is attained, the inhaler should be placed closely 
over the face and the vapor be pushed in a more concentrated form 
for a brief period. Care should be taken that the ether does not 
get into the eyes of the patient, either in vapor or liquid form, owing 
to the irritation which it will set up. To prevent this a piece of 
thin muslin wet with water will be found of service if placed over 
the eyes. All of the early disagreeable effects of ether inhalation 
can be avoided by starting the anesthesia with nitrous oxide gas 
(which see). 

Much of the irritation of the upper respiratory passages produced 
by ether may be avoided by wetting the inhaler with a dram or two 
(4.0-8.0) of an alcoholic solution of menthol (2 per cent.). 

When ether is to be given no solid food ought to be allowed the 
patient for twelve hours preceding its use, in order to avoid vomiting 
during and after the operation, but easily assimilated liquid carbo- 
hydrates, such as barley or rice gruel, may be given later than this 
with advantage. (See Chloroform.) 

The patient should not be allowed to retain any foreign body or 
artificial teeth in the mouth, as they may slip into the larynx and 
cause death while the anesthetic is being given. 

When a general anesthetic is used to prevent suffering, it should 
be remembered that, although it prevents the intellectual centers 
from appreciating pain by blotting out consciousness, and so puts 
aside psychic shock, it does not prevent painful impulses from reach- 
ing the spinal cord and medulla oblongata, the latter being a most 
vital spot. In delicate persons or in severe operations it is often 
advisable to block these impulses by injecting procaine into or 
around the tributary nerve, thereby protecting the central nervous 
system. Some physicians used morphine hypodermically before 



ETHER 281 

operation to benumb the patient's sensibilities with the hope that 
less ether will be required. This is wise in some cases when great 
anticipatory dread is felt. 

Instead of pushing the anesthetic so that very deep anesthesia is 
produced when an important nerve or organ is attacked, it is better 
to let up at this moment, since by this means pain is prevented, but 
the lower vital centers are not subjected to both shock and the drug 
in large amounts at the same moment. 

In operations on the upper air-passages, and those involving the 
thoracic cavity, the method of intratracheal insufflation is now 
largely resorted to, since by this means anesthesia and respiration 
can be carried out even if the patient stops voluntary respiration. 
Before the instrument is introduced into the larynx this organ should 




Fig. 47. — Schema illustrating the direction of motion to be imparted to the laryngeal 
speculum in exposure of the larynx for the introduction of ether insufflation tubes. 
(Chevalier Jackson.) 

be carefully examined to determine its size, its healthfulness, and 
the absence of deformity. The patient should be anesthetized by 
the ordinary open method. The head should be sharply flexed 
backward on the neck, and the neck extended by drawing the head 
from the trunk. The occiput remains on a plane with the table, 
but the cervical vertebrae are arched forward. Jackson insists that 
no gag should be used, as it presses down the lower jaw. The 
speculum must be passed beyond the epiglottis, but not far enough 
to lift the cricoid cartilage. Holding the speculum in the left hand, 
the operator with his right hand elevates the upper lip of the patient 
so it will not be pressed against the teeth. The spatula portion of 
the speculum is passed back over the tongue half an inch beyond 
the tip of the epiglottis. 



282 DRUGS 

The soft catheter through which the anesthetic and air is passed 
is now inserted. 

A very cumbersome and complicated piece of machinery has been 
invented to deliver warm air-pressure ether vapor through the 
catheter. In an emergency the ether can be put in a Wolff bottle, 
which is immersed in warm water (not hot), and connected with 
an ordinary bulb and rubber reservoir, such as is used with an 
atomizer or Paquelin cautery. By this means the air is driven through 
the warmed ether and can pass to the rubber catheter introduced 
into the larynx. 

Under the name of the A. C. E. mixture there is used a compound 
of alcohol, chloroform, and ether, which is but rarely used in America. 
(See Chloroform.) 

Ether may be used as a local anesthetic in an atomizer spray, 
owing to the cold produced by its evaporation when it strikes the 
skin. Thus it is particularly useful in cases where thoracentesis or 
paracentesis abdominis is to be performed, and also in cases of super- 
ficial neuralgia, where the benumbing of the nerve often effects a 
permanent cure. 

Recently ether anesthesia, induced by injecting ether, 6 ounces, 
and olive oil, 2 ounces, into the rectum has been introduced. This 
largely obviates the irritant effects of the older plan of using ether 
by the rectum. The advantages claimed are promptness of action 
and avoidance of post-anesthetic vomiting, as well as a clear field 
in operations about the head and neck. The mixture is introduced 
by means of a funnel attached to a rubber catheter after the bowel 
has been washed clean. If the patient manifests too deep narcosis, 
the mixture is withdrawn by means of a soft-rubber catheter. When 
the operation is over the bowel is washed out with a soapsuds enema, 
and then 2 to 4 ounces of olive oil introduced. The plan is not as 
safe as the inhalation method, as there seems to be much greater 
danger of respiratory paralysis and less opportunity of fitting the 
dose to the needs of each individual. < 

Ether may be used by inhalation to produce muscular relaxation 
when the surgeon desires to reduce a luxation or & strangulated hernia 
by taxis. 

Internal Administration. —When used internally, ether should be 
given in ice-cold water, or, better still, in capsule, in the dose of 30 
minims to J ounce (2.0-16.0). If cold water is not used to dilute it, 
so great is the irritation of the fauces produced by the fumes of the 
drug that deglutition is impossible. 

Internally, by the stomach, ether is very useful in colic, although 
for flatulence of adults and children spirit of ether is a more efficient 
remedy. (See Hoffmann's Anodyne.) In cases of collapse ether, 
given by means of the hypodermic needle or by the stomach, is of 
great service, particularly when cardiac action is very feeble, and 
it will give relief by inhalation in some of these cases more rapidly 
than the nitrite of amyl. 



ETHYL BROMIDE 283 

In hiccough sl few inhalations of ether will often stop the spasmodic 
movements, and other local muscular spasms can be relieved in this 
way. In other instances, a few drops scattered over the belly-wall 
may arrest it. 

Large doses of ether given by the mouth or hypodermically have 
been highly recommended in the treatment of uremia. They are 
most serviceable in the forms in which cardiac and respiratory 
complications are marked. 

In cases where cod-liver oil cannot be digested ether may be given 
in 20 minim (1.3) dose in ice-water or capsule, either with the oil, or 
some minutes after it is taken, to aid in its digestion and absorption. 

The Spiritus JEtheris, U. S. and B. P., is given in the dose of \ to 2 
drams (2.0-8.0). (See also Hoffmann's Anodyne.) 

Contraindications.— Ether should not be used by inhalation in 
bronchitis or pulmonary tuberculosis or acute nephritis, because of 
its irritant properties; in peritonitis or gastritis, because it is apt to 
induce vomiting; in aneurism or in the presence of marked vascular 
atheroma, because it may rupture a bloodvessel by raising arterial 
pressure; nor in diabetes, lest it produce diabetic coma; and if anemia 
is present and an examination of the blood shows that the hemo- 
globin is below 50 per cent., the use of the drug should be avoided 
if possible. 

ETHYL BROMIDE. 

Mthylis Bromidum is obtained by distilling a mixture of alcohol, 
sulphuric acid, and bromide of potassium, and is a colorless fluid of 
neutral reaction, having a pleasant odor resembling chloroform. It 
evaporates with great rapidity, and any sample which does not do 
this is to be discarded. Poured on the hand, it should leave no 
fatty feeling. It should be remembered that the drug is decomposed 
by sunlight and when in prolonged contact with the air. In the 
presence of lamplight the fumes form bromal hydrate and bromine. 
The drug should be kept in dark-glass bottles. The physician 
should distinctly separate in his mind bromide of ethyl from bromide 
of ethylene. The latter is a chemical product possessing very 
dangerous properties, and should never be used in medicine. There 
is reason to believe that many of the unfavorable symptoms which 
follow the use of bromide of ethyl occur only when the drug is impure 
or is improperly used. 

Physiological Action. —According to the studies of Thornton and 
Meixell in the author's laboratory at the Jefferson Medical College, 
the dominant action of the bromide of ethyl is on the respiratory, 
not on the circulatory system. This effect is depressant, but this 
influence is only met with after excessive doses. The blood-pressure 
falls under its influence to a slight degree, and the pulse is slowed 
through an influence probably exercised on the inhibitory nervous 
mechanism of the heart. 



284 DRUGS 

Therapeutics.— Bromide of ethyl is a useful anesthetic for short 
operations, such as opening boils or abscesses, or for the relief of the 
pain in other brief surgical procedures. Originally introduced into 
general use in this country by Levis, it has been found unsuited to 
major surgical cases, because if continued for a long time it seriously 
depresses the respiration. Bromide of ethyl has been found of the 
greatest value by Montgomery, of Philadelphia, as an anesthetic in 
labor and for minor gynecological operations in office practice. He 
finds that the patient may be allowed to inhale the drug from a 
Hawley inhaler, for as soon as she has had enough to produce anes- 
thesia the inhaler drops from her hand. The patient is also more 
obedient to the physician's directions, because of the fleeting influ- 
ence of the drug, than when chloroform or ether is taken, and post- 
partum hemorrhage through uterine relaxation is not so apt to 
occur. 

A very great advantage possessed by bromide of ethyl is the 
rapidity of its action. A few whiffs are generally all that is needed 
to cause anesthesia. It rarely produces disagreeable effects. Cases 
of sudden death under its use are, however, on record, and in some 
instances nervous twitchings, and even tetanic spasms, have been 
known to accompany its employment. These tetanic symptoms are, 
however, fleeting and generally of little importance. Nausea and 
vomiting rarely follow its use, but it is apt to leave an unpleasant 
garlic-like taste in the mouth, and a similar odor of the breath is 
frequently noted for several days after its use. 

Administration.— Bromide of ethyl should be administered for but 
a brief period, but when taken should be inhaled freely. It cannot 
be given carelessly with good effect. If a good sample is employed, 
45 minims to 3 drams (3.0-12.0) is a' sufficient amount to induce 
anesthesia. This quantity should be used at once, instead of added 
to the inhaler drop by drop, as in the case of chloroform, and the 
cloth or inhaler should be held close to the mouth and nose, instead 
of at a little distance, as is often necessary with other anesthetics. 

ETHYL CHLORIDE. 

Ethyl chloride (Mihylis Chloridum, U. S. and B. P.) is a haloid 
derivative (monochlor-ethane, C 2 H 5 C1), prepared by the action of 
hydrochloric acid gas upon absolute ethyl alcohol. 

On account of its extreme volatility, it should be preserved in 
hermetically sealed glass tubes, and kept in a cool place, remote from 
lights or fire. It is a colorless, mobile, very volatile liquid, having a 
characteristic, rather agreeable odor, and a burning taste. Ethyl 
chloride is slightly soluble in water and is readily soluble in alcohol. 
It boils at a temperature of 12.5° to 13° C. (54.5° to 55.4° F.), and 
at its ignition temperature burns with a smoky, green-edged flame, 
with the production of gaseous hydrochloric acid. When liberated 



ETHYL CHLORIDE 285 

at ordinary room-temperatures, from its sealed glass tube, ethyl 
chloride vaporizes at once. The gas is very inflammable, and 
consequently it should not be used in proximity to a gas-flame or 
fire. If 1 cc of ethyl chloride, while cold, be mixed with 20 cc of 
alcohol, and a few drops of silver nitrate solution be added, no 
turbidity should be produced (absence of hydrochloric acid). It is 
constantly used in the form of a spray, as is methyl chloride, for the 
purpose of producing anesthesia by freezing that part of the body 
with which it is brought into contact. 

Physiological Action.— Careful investigations show that ethyl 
chloride is a direct depressant to the heart muscle, but by no means 
so powerful in this influence as is chloroform. In other words, the 
difference is a variation in degree and not in kind. Chloroform is 
nineteen times as powerful in this respect. So, too, ethyl chloride 
may cause a fall of blood-pressure, aside from its depressant effect 
upon the heart, by relaxing the bloodvessel walls, but to a far less 
degree than chloroform. It also decreases cardiac activity by stimu- 
lation of vagus centers in the medulla and not by any reflex irritation. 
Ethyl chloride depresses the respiratory center partly by its direct 
influence and partly by the fall of blood-pressure, whereby this center 
is deprived of blood. When used for anesthetic purposes these effects 
are all very moderate and only become important if cardiovascular 
disease is present. 

Therapeutics.— Ethyl chloride is used not only as a local anesthetic 
by virtue of its freezing properties, but also by inhalation. It is 
necessary when it is given by inhalation, because of its great vola- 
tility, that it should reach the patient in concentrated form, and 
not have an opportunity to be dissipated into the surrounding air 
without first entering the lungs. For this reason it should be used 
by the aid of a mask such as that employed in the administration of 
nitrous oxide gas. The mask should be applied in such a way as 
to cover tightly the nose and mouth, and the ethyl chloride is then 
projected onto a compress which is placed inside of it. Where it 
is impossible to obtain an inhaler made for this purpose, a tin or 
glass funnel may be used as a substitute. The large end of this may 
be placed over the mouth and nose. The neck of the funnel con- 
taining loose absorbent cotton. Through the small end of the 
funnel the chloride of ethyl is sprayed upon the cotton. By the 
careful adaptation of the hands to the sides of the funnel and the 
cheeks it is possible to make this a very close inhaler. 

A good way to keep ethyl chloride is in the form of a graduated 
glass container, so constructed that the drug is measured as the spray 
is forced from it by the heat of the hand. The drug is placed upon 
the market for this purpose in graduated glass containers. 

Anesthesia produced by this method usually develops within fifteen 
to twenty seconds, and its claimed that there are very slight changes 
in the pulse and respiration under its influence— 1 or 2 drams (4.0- 



286 



DRUGS 



8.0) of ethyl chloride are usually sufficient to produce an anesthesia 
lasting from five to ten minutes. Larger amounts than this may be 
employed when a longer anesthesia is desired. It is a noteworthy 
fact that the pupillary and corneal reflexes are not lost under its 
influence except in children, and that this drug cannot be used as 
an anesthetic when muscular relaxation is indispensable. After the 
mask is removed the patient rapidly recovers consciousness and often 
experiences no unpleasant symptoms, although vomiting may occur 
in some cases. It is, so far as is yet determined, a fairly safe anes- 
thetic, but it must be used with care. The 
death-rate under its use is below that of chloro- 
form. In 2550 cases recorded by Lotheisen 1 
death occurred under its effects, but this may 
have been due to organic disease of the coronary 



m-- : - \ 


wSL ^ 




m 


iUe 


4C 


ill— 




|pp— 


-3( 


fk= 


-2( 


; ~ : - 




#= 


-K 




-A 



Fig. 48.— The cap 
unscrews and the drug 
escapes as a fine spray- 
through a small hole in 
the end of the glass. 




Fig. 49. — Showing use of a glass funnel as an inhaler for 
ethyl chloride. 



arteries, which was present. Seitz has collected 1600 cases with 1 
death due to disease of the coronary arteries. Miller has collected 
43,796 cases with 5 deaths, or 1 in 8759 anesthesias. 

Ethyl chloride is often used to produce primary anesthesia before 
giving ether or chloroform. (See Chloroform.) 

Chloride of ethyl is contraindicated if there is any obstruction in 
the air-passages, upper or lower. Serious valvular disease of the 
heart or myocardial degeneration also contraindicate it, and ether is 
probably safer under these conditions. If cyanosis develops during 
its use the drug must be withdrawn at once. It is noteworthy that 
alarming symptoms when they occur develop with great rapidity. 



EUCAINE HYDROCHLORIDE AND LACTATE 287 

The dose varies from 2 to 3 cc in a child to 4 or 5 cc for a 
man. The drug should not be pushed too freely at first and the 
patient should not be deprived of air, except early in the use of the 
drug. Telford and Falconer have shown that ethyl chloride may 
cause post-anesthetic toxemia. (See Chloroform.) 

ETHYLHYDROCUPREIN HYDROCHLORIDE. 

Ethylhydrocuprein hydrochloride (trade name "Optochin") is 
without doubt an efficient destroyer of the pneumococcus not only 
in vitro but in vivo. The recognition of the fact that croupous pneu- 
monia is a general infection, with the chief lesion in the lungs, makes 
it a drug of promise and statistics indicate that if fairly full doses 
are used early it diminishes the mortality from this disease. After 
the exudate is well formed in the lung it does not materially hurry 
resolution and the pneumococci in the exudate are protected from 
the drug. The greatest objection to its use in efficient doses is that 
it has so great a toxic effect upon the optic nerve and retina that 
it may produce not only temporary amblyopia but permanent blind- 
ness. Doses of 7 grains (0.5) three to four times a day exercise a 
bactericidal effect in the blood, but these doses approximate those 
which may produce toxic effects. The daily amount by the mouth 
should not be in excess of 25 grains (1.6). Smaller doses may be 
used with safety to help the body destroy the coccus. It may be 
given in solution; or in capsule if followed by plenty of water, as it 
is prone to irritate the stomach. In the strength of only § grain 
(0.03) to the pint of a 1 to 1500 solution of thymol it is efficient in 
pneumococcus sore-throat when used as a gargle, but it is very bitter. 

EUCAINE HYDROCHLORIDE AND LACTATE. 

Beta-eucaine hydrochloride (Beta-eucaina? hydrochloridum, U. S.) 
is a synthetic substance having a chemical formula closely resem- 
bling that of cocaine. The drug is marketed as a substitute for 
cocaine, it being claimed that it does not affect the heart as does 
the latter drug. Eucaine does not cause a primary contraction of 
the bloodvessels when locally applied, as does cocaine, but a hyper- 
emia of the parts affected. Two forms of eucaine have been used, 
eucaine "A" and eucaine "B;" but the latter is now exclusively 
employed for local anesthesia, and for use in ophthalmic and genito- 
urinary surgery. A solution of eucaine can be sterilized by boiling 
without impairing its properties. Used by the process for produc- 
ing infiltration anesthesia (see Cocaine), eucaine causes considerable 
pain before acting as an anesthetic. For infiltration it should be 
used dissolved in the following formula and warmed before being 
injected: 

I^ — Eucainae hydrochloridi /5 gr. j (0.06) 

Sodii chloridi gr. x (0.6) 

Aquae destillatee f§iij (90.0) 



288 DRUGS 

In ophthalmic practice it is employed in 2 per cent, solution, and 
to ordinary mucous membranes in 5 per cent, solution— that is, 25 
grains (1.6) to the ounce (30.0) of water. One advantage of eucaine 
is that it forms a permanent solution with water in 3.5 per cent, 
strength. 

Beta-eucaine lactate (Benzamine lactas, B. P.) has been intro- 
duced to take the place of the hydrochloride, as it is very much more 
soluble. 

Eucaine hydrochloride possesses a distinct disadvantage in its 
inability to cause primary contraction of the bloodvessels when 
locally applied, and this effect of cocaine is often most valuable to 
overcome local engorgement. Further, it causes severe smarting 
pain when dropped into the eye. 

Eucaine is capable of producing systemic effects resembling those 
due to overdoses of cocaine, and these must be treated by the use of 
strong coffee, alcohol, digitalis and strychnine. If the case is urgent, 
ether and ammonia may be used as rapidly acting stimulants. 



EUCALPYTUS. 

Eucalyptus, U. S., is the leaves of Eucalyptus globulus, or blue- 
gum tree, a native of Australia, but grown at present all over the 
world. Its chief medicinal constituent is the oil of eucalyptus (Oleum 
Eucalypti, U. S. and B. P.), from which is derived Eucalyptol, U. S., 
which is a colorless liquid, obtained by distillation, having a char- 
acteristic, aromatic, and distinctly camphoraceous odor, and a 
pungent, spicy and cooling taste. 'The oil of eucalyptus and eucalyp- 
tol are used for the same purposes, but the latter is the refined 
product of the former. 

Physiological Action.— Locally applied, the oil is a decided irritant. 
10 to 20 minims (0.6-1.3) taken internally cause slight stimulation, 
followed by a sense of calm; while larger doses produce disturbed 
digestion and loose stools of oily odor. The pulse is increased in 
frequency and force, and intense headache may come on. After 
very large doses there is a fall in pulse-force, bodily temperature, 
and strength of limb, and the respirations are decreased. A peculiar 
loss of sensation in the lower limbs may occur. If death takes 
place, it is due to respiratory failure. The drug is eliminated by the 
skin, kidneys, bowels and lungs. The urine may have the odor of 
violets, as it sometimes does after the use of oil of turpentine. 

The oil of eucalyptus has considerable antiseptic power. 

Therapeutics.— Eucalyptus has been used in malarial fever where 
quinine could not be borne by the patient owing to idiosyncrasy. In 
bronchitis, in an emulsion or in capsule, it is of great value in the 
later stages (see Bronchitis), since in its elimination by the lungs it 
acts locally upon the inflamed mucous membrane. It may be used 



EUPHORBIA PI LU LIFER A 289 

in the subacute forms of gonorrhea. The following prescription will 
answer: 

3— Olei eucalypti f 5i (4.0) 

Olei amygdala? expressi f3j (4.0). — M. 

Pone in capsulas, No. x. 
S. — One t. i. d. after meals. 

Eucalyptol, U. S., is obtained from oil of eucalyptus, and is largely 
employed by rhinologists and others in lotions and other nasal appli- 
cations. It may be used in solutions of fatty oils, but is insoluble in 
water, although it is soluble in alcohol and ether. 

Administration.— The fluidextract {Fluidextractum Eucalypti, U. S.) 
is given in the dose of 10 minims (0.6) to 2 drams (8.0), the oil 
(Oleum Eucalypti, U. S. and B. P.) in the dose of 5 minims (0.3), \ 
to 3 minims (0.03-0.18), B. P. The dose of eucalyptol is 5 minims 
(0.3) in capsule. 

Trochiscus Kino Eucalypti and Unguentum Eucalypti are official 
in the B. P., but are seldom used. 

EUONYMUS. 

Euonymi Cortex, B. P., or Wahoo, is the dried bark of Euonymus 
atropurpurea, a native plant of the United States. It contains an 
active principle, Euonymin, B. P. As a laxative its action is very 
slow and mild; it is thought to act particularly on the liver and may 
be used when moderate hepatic torpor is present. 

Administration.— The dose of the solid extract (Extractum Euonymi, 
is 3 to 10 grains (0.2-0.6), of the fluidextract, the dose is 1 to 2 
fluidrams (4.0-8.0). Of euonvmin the dose is J to 1 grain (0.03- 
0.06). 

EUPATORIUM. 

Eupatorium, Thoroughwort, or Boneset is the dried leaves and 
flowering tops of Eupatorium perfoliatum, an American plant which 
is largely used as a simple bitter tonic and diaphoretic in household 
medicine. The drug is generally given in hot infusion in cases of 
arrested menstruation due to cold or in the chill of a remittent or inter- 
mittent fever, and also for anorexia and debility. Its taste is very 
disagreeable. In the dose of a pint (480 cc) of the cold infusion it 
has been used as an emetic. The fluidextract is given in the dose 
of 30 minims to 1 dram (2.0-4.0). 

EUPHORBIA PILULIFERA. 

This herb is sometimes called snake-weed or cat's-hair, and is a 
native of Australia and the West Indies, where, like stramonium, 
it grows profusely as a weed by the roadside. 

Physiological Action.— In toxic doses the drug kills small animals 
by failure of the respiration and circulation, these two vital functions 
19 



290 DRUGS 

being greatly affected by doses which exert no great influence on the 
rest of the body. In full dose it may cause some gastric irritation. 

Therapeutics.— Euphorbia pilulifera is one of the remedies intro- 
duced into medicine for the relief and cure of asthma, in which 
disease the results obtained, after other remedies fail, are very extra- 
ordinary if the reports of those who have given it a thorough trial 
can be accepted without reserve. As yet we do not know the form 
of asthma which is most relieved by its use, and its employment is 
purely empirical. It has also been highly praised in the treatment 
of chronic bronchitis and emphysema. 

Administration.— Euphorbia pilulifera is best given in the form of 
the fluidextract in the dose of 30 minims to 1 dram (2.0-4.0). The 
decoction is made by adding a " handful of stalks with the leaves on 
them to 2 quarts (2 liters) of boiling water, and boiling down to 1| 
quarts (1J liters)." Of this decoction the dose is a small wineglass- 
ful (60.0) three times a day. (See Asthma.) 

EUPHTHALMIN. 

Euphthalmin is a synthetic alkaloid, a derivative of beta-eucaine, 
sometimes called eucatropine, used as an active mydriatic. It 
possesses an effect upon the general system very like that of atro- 
pine, but when first dropped into the eye may cause slight salivation 
through irritation of the secretory fibers of the chorda tympani which 
it reaches after absorption. The pupil under its influence begins to 
dilate in from fifteen to twenty minutes after a few drops of a 2 to 10 
per cent, solution are instilled. The maximum dilatation is reached 
in about an hour, and disappears in about five to eight hours. 
Vinci states that the mydriasis is due to paralysis of the oculomotor 
nerve endings, and that the sympathetic is not affected. 

EUQUININE. 

Euquinine, or quinine ethylcarbonate, occurs as delicate white 
needles, which are tasteless. It is slightly soluble in water, but 
readily so in alcohol, ether, and chloroform. When placed in acid 
mixtures it becomes bitter. Euquinine is used as a substitute for 
quinine, particularly for children, who dislike the bitter taste of the 
older drug and cannot take pills or capsules. 

FLAXSEED. 

Flaxseed or linseed (Linum, U. S. and B. P.) is the seed of Linum 
usitatissimum, or flax from which linen is made; it is official in the 
B. P. as Lini Semina. These seeds contain an oil and a mucilage, 
the first of which is largely used in the arts, and the second is some- 
times employed in medicine. The oil (Oleum Lini, U. S. and B. P.) 
is also used by physicians and pharmacists for various purposes. 



FORMIC ALDEHYDE 291 

Therapeutics.— Flaxseed acts as a demulcent to inflamed mucous 
membranes, and is used largely in the treatment of acute cystitis, 
bronchitis, gastritis, nephritis, and similar states, in the form of flax- 
seed tea. This is prepared by mixing together 3 drams (12.0) of 
flaxseed, not ground, 30 grains (2.0) of extract of liquorice, 10 ounces 
(300.0) of boiling water, and allowing the mixture to stand one to 
four hours in a warm place. If the mixture is boiled, the oil is set 
free and makes the dose disagreeable. This infusion may now be 
made more tasteful and useful by the addition of a little lemon-juice 
and sugar and by the placing of from 1 to 2 drams (4.0-8.0) of gum 
arabic in the pitcher containing it. If the cough is excessive, a little 
paregoric may be added. Linseed oil is used sometimes as a laxative 
in the dose of 2 ounces (60.0), and is said to be of service when so 
given in the treatment of hemorrhoids. 

Flaxseed meal (Lini Farina) when moistened is employed uni- 
versally as a useful poultice. 

Under the name of Carron oil {Linimentum Calcis, U. S.) an 
emulsion of lime-water and linseed oil, equal parts, is a standard 
application for limited or extensive burns. 

FORMIDINE. 

Formidine is a condensation product of iodine, formaldehyde, and 
salicylic acid, and is a true chemical compound. It appears as a 
reddish-yellow powder which is practically tasteless, but possesses a 
slight odor of iodine. It is insoluble in water, dilute acids, alcohol 
and most ordinary solvents, but is slowly soluble in alkaline solu- 
tions. Brought in contact with the juices of the tissues, it slowly 
dissolves and separates into its constituent bodies. 

Formidine is used externally as a dusting-powder for wounds, or, 
in other words, as a substitute for iodoform, as it possesses no dis- 
agreeable odor, is non-irritating, and strongly antiseptic. It may be 
applied either in dusting-powder, ointment, suspended in oils, or 
upon bandages, or it may be diluted with the various dusting- 
powders, such as talc, oleate of zinc, or bismuth. 

Internally it may be given as an intestinal antiseptic, as it is not 
dissolved in the stomach. The best method of administration is to 
give it stirred up in water, milk, coffee, or chocolate. The dose is 
5 to 10 grains (0.3-0.6). Large doses, given to animals, seem to 
prove that it does not produce toxic symptoms. 

FORMIC ALDEHYDE (FORMALDEHYDE). 

Formic aldehyde is a gaseous body difficult of application because 
of its physical characteristics, but nevertheless possessing very great 
power as a disinfectant or germicide. It is prepared by subjecting 
methyl alcohol to oxidation, and almost every instrument maker has 
a device whereby this gas may be generated, and the room formerly 



292 DRUGS 

occupied by a sick person thereby disinfected far more efficaciously 
than can be accomplished by burning sulphur. Some of the smaller 
types of apparatus are, however, quite inadequate. The doors and 
windows of the room should be tightly shut during the process of 
disinfection and for several hours after the formaldehyde generator 
is exhausted. As the gas is exceedingly irritating to the eyes and 
respiratory passages, no one should attempt to enter the room. 
The moistening of fabrics aids the gas in destroying germs. After 
the disinfection is completed the room should be aired for many 
hours, or, if it must be used soon, it may be rendered capable of 
habitation by spraying a 20 per cent, solution of ammonia to neu- 
tralize the acid atmosphere. The great advantage of formaldehyde 
for disinfectant purposes is the fact that it permeates every nook 
and cranny, and yet does no injury to colored fabrics, as does chlorine 
gas under similar circumstances. The safety, efficiency, and cheap- 
ness of formaldehyde gas as a disinfectant, and of the solution, render 
this agent a most valuable one. (See Disinfection.) 

Liquor Formaldehydi, U. S. and B. P., is an aqueous solution of 
formaldehyde which contains 37 per cent., by weight, of the gas. 
It forms a clear, colorless liquid of a pungent odor, which is exceed- 
ingly irritating to mucous membranes. It can be mixed with water 
and alcohol in all proportions, but on standing its solution becomes 
milky because of the separation of paraformaldehyde. It should be 
kept in a cool place protected from light. 

This official solution of formic aldehyde, in the strength of 37 per 
cent., has been widely used of late for disinfectant and antiseptic 
purposes. For all these purposes it is usually diluted still further 
by the addition of water. A 1 per cent, solution is usually quite 
active enough for surgical antisepsis, and is far less poisonous than 
is the bichloride of mercury. A similar percentage, or a little 
stronger, may be used to preserve pathological specimens, and in 
the proportion of 1 to 32,000 it will preserve milk for several days. 
Taken internally, in small amounts well diluted, it does not possess 
any toxic properties, but if its quantity is large or it is in concen- 
trated form it acts as an intense respiratory and gastric irritant. 
The chemical antidote is ammonia water, or the aromatic spirit of 
ammonia, well diluted with pure water. 

Concentrated undiluted formaldehyde solution may be used for the 
purpose of cauterizing syphilitic sores, and it is the specific treatment 
for the bites of rabid animals. 

Formaldehyde is useful when locally applied to check excessive fetid 
sweating, by virtue of its antiseptic effect and because it hardens and 
contracts the skin. The solution used may be made by diluting the 
37 per cent, commercial solution with 4 to 6 parts of water, or using 
"Euformol" diluted or pure as a lotion. Euformol contains eucalyp- 
tus, gaultheria, menthol, boric acid, and formaldehyde, and is pleas- 
anter to use than the crude preparation. Diluted in the proportion 



GALLIC ACID 293 

of 1 to 6 of water it may be employed as a lotion to the entire body 
to check colliquative sweats. 

One teaspoonful (4.0) of the official solution placed in 3 ounces 
(90.0) of sweetened water is a most excellent solution with which 
to kill flies, who greedily take it and speedily die. 

Numerous cases of poisoning by the accidental or suicidal inges- 
tion of formaldehyde solution have been recorded. The symptoms 
consist in epigastric pain which soon becomes diffused and which 
is usually immediate and severe in onset, accompanied by repeated 
vomiting of blood-stained mucus. Sometimes unconsciousness comes 
on almost at once and often lasts for many hours, the symptoms 
resembling those of apoplexy. The suddenness of onset depends 
chiefly upon whether the stomach is empty. When it is full of 
food or liquid, the symptoms do not develop so rapidly. There 
seems to be no doubt that the ingestion of a large dose may produce 
death within a very few minutes in rare cases. Intense inflammation 
of the uvula, pharynx, gullet, and stomach develops, and at autopsy 
these parts are often found eroded and leather-like in character. 
Fatal results in adults have followed the ingestion of 3 ounces of 
the ordinary formaldehyde solution. The smell of the vomit is 
diagnostic. The chemical antidote is ammonia water, well diluted, 
or any one of the ammonium salts, well diluted, such as ammonium 
acetate. The stomach should then be washed out, and soothing 
drinks, such as sweet oil and starch-water, given with morphine 
hypodermically for the relief of pain. 

GALLIC ACID. 

Acidum Gallicum (U. S. and B. P.) is usually prepared from tannic 
acid. It occurs in nearly colorless, long, needle-like crystals, which 
are soluble in 87 parts of cold water at 25° C. (77° F.), 4.6 parts 
of alcohol, and 3 parts of boiling water. 

Physiological Action.— Gallic acid is an astringent, but not a coag- 
ulator of blood. Locally applied in bleeding, it is useless, but given 
internally in hemorrhages which cannot be acted upon by the direct 
local application of tannic acid, it is thought to be useful as a hemo- 
static because it contracts the bloodvessels. This is very doubtful. 
It is eliminated from the body by the kidneys as gallic acid. 

Therapeutics.— Gallic acid has been used in albuminuria dependent 
upon a relaxed, atonic state of the kidneys and in acute or chronic 
diarrhea with advantage. In the form of the ointment it is useful 
in the treatment of psoriasis, and in the cure of ulcers and sores which 
are actively discharging. A very useful application to external hemor- 
rhoids is equal parts of stramonium ointment and gallic acid. 

Administration.— Gallic acid is given in the dose of 2 to 40 grains 
(0.12-2.6) in pill or solution. It ought never to be used with any 
salt of iron, as it is chemically incompatible. The preparation used 
locally is Unguentum Acidi Gallici. 



294 DRUGS 

Nut-gall. 

Nut-galls (Galla, U. S. and B. P.) are the small excrescences 
found upon the oak (Quercus infectoria) formed by the ova of the fly 
Cynips tinctoria. Their sole value depends upon the tannic acid 
contained in them. The ointment (Unguentum Gadce, U. S. and 
B. P.) and Unguentum Gallce cum Opii, B. P., are used as astringent 
and sedative applications. 

GAMBIR. 

Gambir, U. S., is an extract derived from the leaves and young 
shoots of Ouronparia gambler. It takes the place heretofore held by 
catechu. Gambir depends for its medicinal value upon the astrin- 
gent properties which it possesses. Beyond this power it has no 
particular value. 

It is of a dark-red color, has a somewhat sweetish taste, and is 
insoluble, like most extracts, in water. 

Therapeutics.— Like all the vegetable astringents, gambir is used as 
a remedy for diarrhea, particularly that of the serous type or that in 
which the stools are of too fluid a consistence. If large amounts of 
mucus in the passages show a catarrhal state of the bowel, the mucus 
should be displaced by a purge of castor oil or sulphate of magnesium 
before the astringent is used. 

Gambir may or may not be combined with opium in cases of 
diarrhea, and the following prescription will be found of service in 
many instances: 

For an adult: 

IJ — Tincturae gambir compositse f S i j (60.0) 

Tincturse opii camphoratse f 5ij (60.0) 

Misturse cretse f 5ij (60.0).— M. 

S. — Dessertspoonful (8.0) every four hours until relieved. To be shaken before using. 

In cases of sore-throat where the secretion is excessive and the 
inflammation subacute, gambir may be used as a gargle. 

In cases of spongy gums gambir is sometimes useful as a mouth- 
wash. If the powdered gambir is used internally, the dose is 20 to 
30 grains (1.3-2.0). The dose of the compound tincture of gambir 
(Tinctura Gambir Composita, U. S.) is 1 to 2 fluidrams (4.0-8.0). 
Its only constituent besides the gambir is cinnamon. The troches 
of gambir (Trochisci Gambir, U. S.) are employed in sore-throat, 
and are to be held in the mouth. They are not generally used. 

In the B. P. gambir is still official as catechu and the following 
preparations are also official: Trochiscus Catechu; the tincture 
(Tinctura Catechu), dose \ to 1 fluidram (2.0-4.0); and a compound 
powder (Pubis Catechu Compositus), composed of catechu, kino, and 
rhatany, the dose of which is 10 to 40 grains (0.6-2.6). 



GELSEMIUM 295 

GAULTHERIA. 

Wintergreen, or Gaultheria procumbens, is an American evergreen 
containing a volatile oil. The oil possesses a peculiar, exceedingly 
penetrating odor and a warm aromatic taste. It is about 96 per cent. 
salicylate of methyl. The Salicylate of Methyl (Methylis Salicylas, 
U. S.) is derived from the oil or as an artificial product. 

Physiological Action.— Owing to the large amount of salicylate of 
methyl contained in the oil, its physiological action is almost identical 
with that of salicylic acid. (See Salicylic Acid.) 

Therapeutics.— Aside from its use as a flavoring substance, oil of 
gaultheria may be used in place of the ordinary salicylates in all 
forms of rheumatism in which they are useful. This oil is best given 
in capsules or emulsion or dropped on a teaspoonful of sugar three 
times a day after meals. The dose may be as high as 100 minims 
(6.6) a day, but if 60 minims (4.0) three times a day are without 
effect, pushing it further is useless. Very few patients can take 
more than 30 minims a day without suffering from a disordered 
stomach. 

Lannois and Limousin have highly recommended the application 
of this oil to acute and chronic rheumatic joints. The oil is placed 
on lint, and then the lint is wrapped around the part affected, evapo- 
ration being prevented by applying a gutta-percha covering. They 
assert that this treatment gives rapid relief, although they admit 
that after it the skin may desquamate. 

GELSEMIUM. 

Gelsemium, U. S., and Gelsemii Radix, B. P., or yellow jasmine, 
as used in medicine is the dried rhizome and roots of Gelsemium 
sempervirens, a climbing plant of the Southern United States. It 
contains two alkaloids, gelsemine and gelseminine. 

Physiological Action.— Nervous System.— Gelsemium paralyzes the 
spinal cord, particularly on its sensory side, although the motor side 
is certainly ultimately depressed. It does not influence the nerves or 
muscles except those of the head, on which it acts as a paralyzant, 
particularly affecting the motor fibers. 

Circulation.— Gelsemium is a depressant to the circulation, act- 
ing particularly on the heart. It paralyzes the vagus and lowers 
blood-pressure. 

Respiration.— Gelsemium kills by paralyzing the respiratory cen- 
ters (Sanderson, Ringer, and Murrell). 

Temperature.— In overdose the drug lowers bodily heat very 
markedly. 

Eye.— Gelsemium is a mydriatic of considerable power, causing, 
when dropped into the eye, wide dilatation of the pupil, a result 
due to paralysis of the oculomotor nerve peripherally. 



296 DRUGS 

Therapeutics.— Gelsemium is used in headache and migraine depend- 
ing on nervous troubles or upon eye-strain. It is particularly useful 
in combination with cannabis. (See Cannabis and Migraine.) 

In malarial fever it is said to be of service, but this is doubtful. 
In the early stages of pneumonia and pleurisy as a substitute for 
aconite it was highly spoken of by Bartholow. 

Gelsemium has also been found of value in asthma, whooping-cough, 
laryngismus stridulus, and nervous cough. In localized muscular 
spasm, such as is seen in torticollis or wryneck, and in spasmodic 
dysmenorrhea, it is of considerable service. It ought not to be used 
if the system is already depressed, but only in sthenic cases. 

When used as a mydriatic, Tweedy recommends gelsemine as equal 
to atropine in effect, but much more transient in its influence. He 
uses 8 grains of commercial gelsemine to the ounce (0.5-30.0) of 
water instilled, drop by drop, into the eye every fifteen minutes for 
one hour, and then every half -hour for two hours. 

Poisoning.— The most prominent symptoms of gelsemium poison- 
ing are ptosis and dropping of the jaw. These are preceded by a 
sensation of languor, a desire to lie down, relaxation and muscular 
weakness. Gelsemium is apt to cause temporary internal squint, 
owing to its paralyzant action on the sixth pair of cranial nerves. 
The pulse becomes rapid and feeble, the skin wet and cold, the face 
pinched and anxious, the voice is lost, and death ensues from centric 
respiratory failure and an almost simultaneous cardiac arrest. Sen- 
sation in man is impaired very late in the poisoning. 

The treatment of the poisoning consists in the use of cardiac stimu- 
lants, such as ammonia and digitalis, the application of external heat, 
and the employment of atropine and strychnine for the purpose of 
stimulating the respiratory center. Emetics and the stomach-pump 
are, of course, to be employed if the patient is strong enough. 

Administration.— The nuidextract (Fluidextr actum Gelsemii, U. S.) 
is given in the dose of 2 to 5 minims (0.1-0.3) and the tincture 
Tinctura Gelsemii, U. S. and B. P.) 5 to 15 minims (0.3-1.0). Extrac- 
tum Gelsemii, U. S., is given in the dose of J grain (0.015). In 
some parts of the United States physicians largely employ a very 
strong unofficial tincture of gelsemium, the dose of which is 1 to 2 
minims. Gelsemine and gelseminine should not be given internally. 

GENTIAN. 

Gentiana, U. S., is the root of Gentiana lutea, or yellow gentian, 
a European plant. It contains gentianine and gentisic acid, and has 
a bitter taste. This drug is official in the B. P. as Gentianw Radix. 

Therapeutics.— Gentian is one of the most efficacious bitter tonics 
that we possess. In the anorexia following acute diseases and in 
cases of gastric atony with dyspepsia it is of value. Combined with 
bicarbonate of sodium, it is of great service in the treatment of the 
subacute gastric and intestinal catarrh of children. 



GLANDULAR EXTRACTS 297 

Administration.— The compound tincture {Tinctura Gentianoe Com- 
posita, U. S. and B. P.) is given in the dose of 1 to 2 drams (4.0- 
8.0), i to 1 fluidram (2.0-4.0), B. P., the fluidextract (Fluidez- 
tractum Gentianoe, U. S.) in the dose of 30 minims to 1 dram (2.0- 
4.0), and the solid extract (Extractum Gentianoe, U. S. and B. P.) 
in the dose of 1 to 8 grains (0.06-0.5). Infusum Gentianoe Comvosi- 
tum, B. P., is given in the dose of J to 1 fluidounce (15.0-30.0) . The 
compound tincture and compound infusion are composed of gentian, 
bitter orange peel, and cardamoms. The following prescription is 
an excellent one for use in convalescence from prolonged fevers: 

1$ — Acidi nitrohydrochlorici diluti .... f5j vel f 3ij (4.0-8.0) 

Tincturae nucis vomicae f 3 J (4.0) 

Tincturse cardamomi compositae . . . f 5ij (60.0) 

Tincturae gentianae compositae . q.s. ad fSiv (120.0). — M. 

S. — Teaspoonful (4.0) in water after meals. 

GINGER. 

Zingiber, U. S. and B. P., is the rhizome of Zingiber officinale, a 
plant of Hindostan, Jamaica, and other tropical countries. Black 
ginger is the dried rhizome with its bark, while white ginger has this 
covering removed. It contains a hot volatile oil and an aromatic 
resin, and is largely used in domestic medicine as a carminative and 
stomachic. In the treatment of menstrual cramps it is often given, 
and is particularly useful in those cramps due to suppression from 
exposure to cold. Ginger is often combined with purgative medicine 
to prevent griping and for its pleasant flavor. It is decidedly con- 
stipating, and when used in diarrhea mixtures is of value other than 
as a flavoring addition to the prescription. 

Administration.— The fluidextract (Fluidextr actum Zingiberis, TJ.S.) 
is given in the dose of 10 to 30 minims (0.6-2.0), well diluted; the 
tincture (Tinctura Zingiberis, U. S. and B. P.), dose 20 minims to 
2 drams (1.3-8.0); the syrup (Syrupus Zingiberis, U. S. and B. P.), 
dose 30 minims to 2 drams (2.0-8.0), J to 1 fluidram (2.0-4.0), 
B. P.; the oleoresin (Oleoresina Zingiberis, U. S.), dose J to 1 minim 
(0.03-0.05), well diluted or in pill. The troches ( Trochisci Zingiberis) 
are used as stimulants to salivary secretion. 

GLANDULAR EXTRACTS. 

Within the past two decades physiological investigations have 
proved that several glands in the body pour out into the blood- or 
lymph-vessels ferments or substances which perform definite physio- 
logical functions in the system. Disease of these glands perverts 
these functions, and secondary disorders follow. Acting upon the 
discoveries just named, some persons have attempted to show that 
nearly all of the organs of the body, be they glands or not, possess 
these functions, until they have reached a reductio ad absurdum. On 



298 DRUGS 

the other hand, some of the glands are now used, when derived from 
the lower animals, for definite therapeutic purposes, such as the 
thyroid gland and the suprarenal bodies, for example. The use of 
these glands will be found discussed under their own names, but 
unimportant glands in therapy, or those in regard to which doubt 
exists, are included under the general heading here given. (See 
Thyroid Gland, Pituitrin, and Suprarenal Gland.) 

The employment of testicular juice, or the dried gland itself, has 
been practically abandoned, but the dried corpus luteum seems to 
possess considerable power. It has been used to combat the symp- 
toms following double oophorectomy and those common to the 
menopause, and also for aphrodisiac purposes. On the ground that 
chlorosis is due to a faulty internal secretion of the ovary, it has been 
given in this condition with asserted good results, and also in osteo- 
malacia, neurasthenia, and hysteria in females. The dose is from 
2 to 4 grains (0.1-0.2) three times a day. (See Corpus Luteum.) 

The use of cerebral and spinal extracts has proved futile, as has 
also the use of bone-marrow, in pernicious anemia. The pancreas 
has been used in pancreatic diabetes, but its value is in doubt. The 
liver has been given in the dose of 3 ounces (90.0) of fresh gland a 
day to combat the delirium of cirrhosis, with asserted good results 
(Carnot), and has been thought to do good in alcoholic cirrhosis with 
icterus, in that the hemorrhages were arrested, the delirium ceased, 
and the patient generally improved. The same treatment has been 
tried in diabetes. It is difficult to see how it can be of benefit. 

While glandular therapeutics gives promise of aiding greatly in 
the treatment of disease, and while for this reason the cautious 
physician should not oppose resort to the use of glandular extracts, 
he should, nevertheless, always study the physiological function of 
the gland to be employed in order that he may reach a clear idea of its 
remedial possibilities. The extraordinary effects of some glands do 
not prove that all animal extracts are of value, nor does the failure 
of others indicate that all are useless. 

GLYCERIN. 

Glycerinum, U. S. and B. P., sometimes called glycerol, is a liquid 
obtained by the decomposition and distillation of fats. It is a clear, 
colorless liquid, of a thick, syrupy consistence, smooth to the touch, 
odorless, sweet to the taste, which produces a sensation of warmth in 
the mouth. When exposed to the air, it absorbs moisture. It is 
soluble in all proportions in water and alcohol also soluble in a 
mixture of 3 parts of alcohol and 1 part of ether, but insoluble in 
ether, chloroform, carbon disulphide, petroleum benzin, benzene, and 
fixed and volatile oils. 

Glycerin is slowly volatilized from weak aqueous solutions, at or 
above 100° C. (212° F.), with the vapor of water. At boiling tern- 



GLYCERIN 299 

peratures 70 per cent, to 100 per cent, glycerin rapidly volatilizes; 
95 per cent, glycerin boils at 165° C. (329° F.); anhydrous glycerin 
boils at 290° C. (554° F.) without decomposition. Under continued 
heat it is finally entirely decomposed and dissipated. 

An aqueous solution of glycerin is neutral to litmus paper. It 
possesses great power in absorbing water and of dissolving many 
substances. Even if pure it irritates the skin of susceptible persons 
when applied locally, by its absorption of water, and often causes a 
slight rash. 

Physiological Action.— Injected into the circulation in large amounts, 
glycerin causes convulsions, which are due to its hygroscopic power. 

According to the clinical researches of Pavy, glycerin increases the 
polyuria of diabetes almost one-half, and for this reason he thinks 
it is not to be employed in this class of cases as a substitute for sugar. 
Other clinicians, however, have disagreed with him and use it con- 
stantly for this purpose with asserted advantage, but saccharin has 
largely supplanted it. 

Therapeutics.— Glycerin may be employed as a sweetening agent 
in the food of diabetics and in cases where sugar cannot be used. It 
has also been given as a laxative in 1- or 2-dram (4.0-8.0) doses by 
the mouth, and in enema— 1 to 4 drams (4.0-16.0) with or without 
equal parts of water. (See Magnesium Sulphate.) In some cases 
it may be used in suppository in the official Suppositoria Glycerini, 
U. S. and B. P. This latter method is very successful in chronic 
constipation. Its continued use by suppository may, however, result 
in rectal irritation. 

As an antiseptic it is used for preserving specimens and for keeping 
alkaloids in solution for hypodermic use. 

In acute coryza, applied by a spray or brush to the nostrils, it is 
sometimes of service; for this purpose it should be diluted four or five 
times with water. If used on the skin, it should be diluted one-half 
with water. In cases of impacted cerumen in the external auditory 
canal glycerin is often of service in softening the mass. 

The uses of glycerin, other than those mentioned, are many. In 
the proportion of equal parts of glycerin and water it makes a very 
useful mouth- wash for the sore and dry mouth of typhoid fever and for 
the removal of sordes. The same wash, with lemon-juice added to 
it, is very agreeable and will relieve the dry, glazed tongue of advanced 
phthisis. 

Owing to the fact that glycerin is hygroscopic, it may be used as a 
depletant on a pledget of cotton in congestion of the uterine cervix, 
the tampon being renewed daily. 

For the prevention of bed-sores Ringer recommends the daily 
washing and rubbing of the part likely to be affected, followed by 
the application of glycerin and water, with a draw-sheet placed 
"smoothly against the patient to protect the bedding. 

Glycerin and whisky is a favorite household remedy for colds and 



300 DRUGS 

coughs, but is not very useful. Glycerite of starch ( Glyceritum Amyli, 
U. S.; Glycerinum Amyli, B. P.) is used as a protective over super- 
ficial irritations of the skin. Glycerite of yolk of egg (Glyceritum 
Vitelli) is used in making emulsions. 

A very useful ointment for the application of medicinal substances 
to the skin may be made by constantly mixing in the presence of heat 
1 part of potato starch and 15 parts of pure glycerin. The result is 
a clear, transparent, jelly-like substance which does not decompose, 
and has the advantage of holding the medicament which it carries 
in solution rather than by mechanical suspension. 

The B. P. preparations of glycerin are as follows: Glycerinum 
Acidi Carbolici, Glycerinum Acidi Tannici, Glycerinum Aluminis, 
Glycerinum Acidi Borici, Glycerinum Plumbi Subacetatis, Glycerinum 
Tragacanthce, Glycerinum Boracis, Glycerinum Pepsini, Glycerinum 
Amyli, and Unguentum Glycerini Plumbi Subacetatis. 

GLYCERITE OF BOROGLYCERIN. 

The glycerite of boroglycerin (Glyceritum Boroglycerini, U. S-) is 
made by heating 460 Gm. of glycerin, in a tarred porcelain dish, to a 
temperature not exceeding 150° C. (302° F.), and adding the boric 
acid, 310 Gm., in portions, constantly stirring. When all is added 
and dissolved, continue the heat at the same temperature, frequently 
stirring, and breaking up the film which forms on the surface. When 
the mixture has been reduced to the weight of 500 Gm., add to it 
500 Gm. of glycerin, mix thoroughly, and transfer it to suitable 
vessels. It is soluble in water. 

Locally the glycerite of boroglycerin is used as an antiseptic and 
as a vehicle for phenol, chrysarobin, and the vegetable alkaloids in 
the treatment of skin diseases, and in diseases of the eye, such as 
purulent ophthalmia. It is also used on vaginal tampons to deplete 
the surrounding tissues. 

GOLD. 

Gold itself is not official in the U. S. P., but was recommended 
very highly by Bartholow in chronic Bright 's disease in the form of 
the chloride of gold and sodium (Auri et Sodii Chloridum, U. S.). 
The dose of this substance is -£$ to yq grain (0.003-0.006) once, twice, 
or thrice a day. The author has not found it of any value. Gold 
has also been strongly recommended for indigestion with epigastric 
pain after eating when looseness of the bowels is present, and it is 
said to act as a powerful sexual stimulant and to be of service in 
impotence dependent upon inability to obtain an erection or when 
there is deficient glandular action. It has also been used in excessive 
nocturnal emissions in masturbators, with asserted great success. In 
overdoses the drug causes gastro-enteritis. Magruder has recom- 
mended chloride of gold and sodium in the treatment of pertussis. 



GUAIAC 301 



GRINDELIA ROBUSTA. 

Grindelia, U. S., is an American plant (Grindelia robusta) containing 
a resin, a volatile oil, and an alkaloid. 

Physiological Action.— Upon the lower animals and man this drug 
is not very powerful in its action, but may cause, in large doses, par- 
alysis of the peripheral sensory nerves, the sensory centers in the 
spinal cord, and finally the motor centers and nerve-trunks. It 
slows the heart by stimulating the vagi, and raises blood-pressure by 
stimulating the vasomotor center. 

Therapeutics.— Grindelia robusta is an exceedingly useful remedy 
in some cases of asthma and in bronchitis in its later stages. It may 
be given in the dose of 20 to 60 minims (1.3-4.0) of the fluidextract 
(Fluidextractum Grindelice, U. S.), or by inhaling the fumes of burn- 
ing grindelia leaves, which have been previously soaked in a solu- 
tion of nitre, dried, and burned on a plate or rolled into a cigarette 
and smoked. In chronic cystitis it stimulates the bladder and is of 
service. By diluting it 1 to 10 with water it forms one of the best 
lotions that we have for the relief of the dermatitis produced by poison 
ivy, or Rhus toxicodendron. 

Administration.— The only preparation which is official is the fluid- 
extract (Fluidextractum Grindelice, U. S.), dose 20 to 60 minims 
(1.3-4.0). 

GUAIAC. 

Lignum vita?, or Guaiacum officinale, a West Indian tree, is used 
in medicine as guaiac resin (Guaiacum, U. S.; Guaiaci Resina, B. P.), 
which is soluble in alcohol, ether, and chloroform, but is insoluble in 
water. 

Therapeutics.— Guaiac has been largely used in syphilis, but is now 
rarely, if ever, so employed. Given in acute tonsillitis in the dose of 
30 grains in an emulsion made by the use of white of egg, it will often 
abort an attack. In rheumatism it has been largely used. In the 
treatment of gout, Luff has highly commended it as a preventive 
given in cachet or capsule in the dose of 5 grains (0.3) of the powdered 
resin three times a day and gradually increased to 10 grains (0.6) at 
a dose. The ammoniated tincture of guaiac is sometimes employed 
in the treatment of sore-throat, particularly if it be rheumatic in type, 
but it is a disagreeable preparation to take into the mouth, and the 
salicylates may always be used in its place. 

Administration.— The tincture (Tinctura Guaiaci, U. S.) is given in 
the dose of 5 to 60 minims (0.3-4.0), and the ammoniated tincture 
(Tinctura Guaiaci Ammoniata, U. S. and B. P.) is used in the same 
dose, preferably in milk. Mistura Guaiaci, B. P., is given in the dose 
of | to 1 fluidounce (15.0-30.0). Trochiscus Guaiaci Resina are 
official in the B. P. 



302 DRUGS 



GUAIACOL. 



Guaiacol (U. S. and B. P.) is a liquid constituting from 60 to 90 
per cent, of creosote. It is obtained by the distillation of beechwood 
creosote, followed by a complicated process which it is not necessary 
to describe. In other cases guaiacol is obtained from beechwood 
creosote by precipitation with barium hydrate. In still other 
instances a very pure crystalline solid guaiacol is made synthetically 
from pyrocatechin. Much of the " absolute guaiacol" of commerce 
is impure. Chemically pure guaiacol, obtained by the process last 
named, is a light-colored crystalline solid of an agreeable odor and 
soluble in water in the proportion of 1 to 53. It is readily soluble in 
alcohol and ether. As it melts at 83.5° F., it usually is dispensed 
in a fluid form. 

Therapeutics.— Guaiacol has been largely used by some practition- 
ers, chiefly in Europe, in the treatment of tuberculosis as a substitute 
for creosote, because it is the principal ingredient of that drug. 
(See Creosote.) It was thought by Guttmann, Sommerbrodt, and 
others that the good effect of creosote was due to its destructive 
action on the bacillus, or that it so improved digestion as to indirectly 
increase the resistance of the patient to the spread of the disease. 
Hoelscher and Seifert have asserted that guaiacol and creosote pro- 
duce their good effects by forming compounds with the toxins or 
poisonous albuminoids formed by the bacilli, which are then elimin- 
ated from the body. There is no proof of this. 

The same rules govern the use of guaiacol as govern the employ- 
ment of creosote. It is best given with brandy, wine, or other 
alcoholic drink, or in capsule with cod-liver oil or sweet oil. 5 or 10 
minims (0.3-0.6) of guaiacol may be added to a pitcher of hot water 
and the vapor inhaled three or four times a day in cases of subacute 
and chronic bronchitis. The dose by the stomach is 5 to 20 minims 
(0.3-1.3). In acute follicular tonsillitis pure guaiacol may be painted 
over the tonsils with advantage. Indeed, it is the best application 
for this purpose, in its early stages, but it is at first very painful. 

Clinical observations prove conclusively that guaiacol possesses 
powerful antipyretic influences. As pointed out by Sciolla in 1893, 
guaiacol when painted on the skin of a febrile patient causes a pro- 
nounced fall of temperature, which begins soon after the application 
is made, but is not fully accomplished for from two to three hours. 
The application may be made to the skin of the abdomen, thighs, or 
chest, about 30 to 40 minims (2.0-2.6) being used with a brush. When 
a full effect is required, it is well to place an impermeable dressing 
over the part painted to prevent evaporation and aid absorption. 
These applications may be resorted to as often as is necessary for the 
reduction of the fever, and, although the fall of temperature is 
sometimes very rapid— as much as 7° F. in two hours— the late 
Prof. J. M. Da Costa asserted that he never had seen serious nervous 



GUAIACOL CARBONATE 303 

or cardiac symptoms produced, but other observers have noted such 
untoward results. The temperature is very apt to rise speedily after 
the reduction, and this rise is often preceded by a chill. These 
applications cannot supplant the cold bath, although they undoubt- 
edly do reduce the temperature. The true sphere of usefulness to 
be assigned to guaiacol as an antipyretic seems to be that of a far 
less valuable therapeutic measure than the bath, and one equally 
powerful and about as dangerous as are the antipyretic drugs of 
coal-tar derivation. 

The studies of Stolzenberg show that if frequently and constantly 
used guaiacol produces in febrile patients a tendency toward depres- 
sion. Thayer found that great sweating and depression generally 
follow its external use in fevers. Future reports will probably develop 
the fact that in cases of renal irritation guaiacol will prove harmful. 

Guaiacol has been used by painting it on the affected part in the 
treatment of superficial neuralgias, and in deep-seated nerve-pains, 
as in sciatica, it has been given hypodermically, in the dose of 2 
minims in 10 minims of spirit of chloroform, injected deeply into 
the neighborhood of the painful nerve. This is dangerbus. 

If guaiacol is placed upon the skin by means of a small compress, 
which has been wet with it and bound tightly to the part, local anes- 
thesia is rapidly developed; but if left in place too long, it may be 
absorbed in sufficient amount to cause depression or a fall of tem- 
perature. 

Belfield highly recommends painting the scrotum with guaiacol 15 
minims (1.0) and glycerin 45 minims (3.0) for orchitis, or an ointment 
of guaiacol 1 dram (4.0) to 4 drams (16.0) of lanolin may be rubbed 
into the scrotum and applied on lint. This should be applied every 
other day. 

A serious objection to the external use of guaiacol is its disagree- 
able odor. 

GUAIACOL CARBONATE. 

Carbonate of guaiacol (Guaiacolis Carbonas, U. S. and B. P.) is a 
white crystalline powder, consisting of 91.5 per cent, of pure guaiacol 
and 8.5 per cent, of carbonic acid. This powder is insoluble in water, 
soluble in 60 parts of alcohol and 1 part of chloroform, neutral in 
reaction, and is said to be without irritating effect on the stomach. 
Taken by the healthy individual, it is decomposed into guaiacol and 
carbonic acid in the bowel, but not in the stomach, and it is used for 
this reason, as salol is, as an intestinal antiseptic, in the various forms 
of fermentative diarrhea and typhoid fever. The drug is said to be 
slowly absorbed, but after absorption is rapidly eliminated. Its 
therapeutic applications in tuberculosis are practically identical with 
those of pure guaiacol, save that it is more readily borne by the 
stomach than the latter drug. Guaiacol carbonate may be given in 
capsule or pill, or it may be given in dry powder on the tongue in the 



304 DRUGS 

dose of 2 to 10 grains (0.12-0.6). Usually in typhoid fever the dose 
is about 2 grains (0.12) every three hours, and in tuberculosis of the 
lungs 5 grains (0.3) three times a day. 



HflMATOXYLON. 

Hcematoxylon, Hwmatoxyli Lignum, B. P., or logwood, is the heart- 
wood of Hcematoxylon campechianum, a tree of the American tropics. 
It contains an active principle, hematoxylin. 

Therapeutics.— Hsematoxy Ion is a mild astringer, very useful in 
serous diarrheas and the diarrheas of young children as children do 
not dislike it, owing to its agreeable taste. (See article on Diarrhea.) 
As it colors the stools and urine red, the nurse should be warned lest 
she be alarmed at the sight of what looks like blood on the diaper after 
the drug is given to infants.' If the urine is alkaline, the color may be 
violet or red. In leucorrhea its internal use is said to be of service. 
The extract) Extractum Hwmatoxyli) is given in the dose of 8 to 30 
grains (0.5-2.0), and Decoctum Hwmatoxyli, B. P., in the dose of 1 
to 2 fluidounces (30.0-60.0). An unofficial fluidextract is often to 
be found in the shops. The dose of this is J to 2 fluidrams (2.0-8.0). 
(See article on Diarrhea.) 

HAMAMELIS. 

Hamamelidis Cortex and Hamamelidis Folia, B. P., witch-hazel, or 
Hamamelis virginiana, is a plant of the United States, devoid of 
any active principle, but possessing considerable remedial power. 

Therapeutics.— Hamamelis is to be employed in relaxed sore-throat 
resulting in congestion and hyperemia following exposure or where 
mild catarrhal states are present. Similarly, it is employed in an 
atomizer, after attacks of acute coryza, to tone up the nasal mucous 
membrane. The strength of the solution should be 20 to 60 minims 
(1.3-4.0) of the distilled extract to the ounce (30.0) of water. Hama- 
melis when taken internally is often very successful in the treatment 
of uterine oozing from small bloodvessels, seems to do good even in 
hematemesis, and will sometimes arrest hematuria when other remedies 
fail. Applied by means of cloths to recent leg ulcers, it rapidly relieves 
the angry-looking skin surrounging the ulcer. The limb should be 
elevated and at rest while the treatment is pursued. In bleeding from 
the bladder it may be injected into this viscus daily in the form of 
the distilled fluidextract. Taken internally and applied locally, it 
is of value in the treatment of bleeding and the so-called blind piles. 
(See Hemorrhoids.) 

Administration.— The official preparation in the U. S. P. is the dis- 
tilled extract (Aqua Hamamelidis, U. S.), which is a perfectly clear 
fluid, given in the dose of from 30 minims to 1 dram (2.0-4.0) . It is 



HEXAMETHYLEN AMINE 305 

much the best preparation for internal and external use. The B. P. 
recognizes a solution, Liquor Hamamelidis, Tinctura Hamamelidis, 
and Unguentum Hamamelidis and Extr actum Hamamelidis Liquidum. 

HELMITOL. 

Helmitol is hexamethylen-tetramine anhydro-methylen-citrate. It 
occurs as a white crystalline powder, of slightly acid taste, and is 
soluble in water 1 to 10 parts. 

In action it closely resembles hexamethylenamine (which see), 
but gives off formaldehyde from both its hexamethylen-tetramine 
and its anhydro-methylen-citrate. It is said to be a much more 
powerful urinary antiseptic than hexamethylenamine, and to be 
equally efficacious whether the urine be acid or alkaline. It is also 
said to be less irritant to the kidneys. Helmitol is used for all the 
purposes named under "Hexamethylenamine." The dose is 5 to 15 
grains (0.3-1.0), dissolved in water, three or four times a day. 

HEROIN. 

Heroin (Diacetylmorphinoe hydrochloridum, U. S.; Diamorphinw 
hydrochloridum, B. P.) is a white crystalline powder without odor 
and possessing a slightly bitter taste. It is used in medicine for 
the purpose of controlling excessive cough. Under its influence the 
respirations are usually slightly slowed and deepened. At one time 
it was thought to be less depressant to the respiratory center than 
morphine, and even stimulant in its influence, but Cushny has shown 
that it is a more powerful respiratory depressant than morphine. 
The dose is ■%■$■ to J grain (0.003-0.01), three times a day. Large 
doses do not act as well as small ones as a rule. It is said to be of 
value in uremic dyspnea. The fact that it does not stupefy the 
patient nor produce constipation is strongly in its favor. As heroin 
is insoluble, hydrochloride of heroin is the preparation used for watery 
solutions; or heroin itself may be dissolved in water to which a little 
acetic acid has been added. It may also be given in pill or powder 
with white sugar. Like all derivatives of opium its repeated use 
may develop a habit. 

HEXAMETHYLENAMINE. 

Urotropin (Hexamethylenamine, U. S., H examine, B. P.), also made 
in the United States under the name Uritone, is produced by the 
action of ammonia upon formaldehyde, and appears in colorless 
crystals which are odorless and have an alkaline reaction. At 77° F. 
it dissolves in 1.5 parts of water. When taken internally it sets free 
formaldehyde in the urine. Burman states that 10 grains three 
times a day will give approximately 1 : 5000 of formaldehyde in the 
20 



306 DRUGS 

urine. Formaldehyde appears in the urine in from one to three 
hours after a dose is given, its maximum appears in from four to 
eight hours. It is used to render the urine acid 'and clear when 
this secretion is excessively alkaline, loaded with phosphates and 
amorphous urates, and purulent. It allays irritability of the blad- 
der due to this cause, as, for example, that due to ammoniacal 
cystitis. In pyelitis and cystitis the microorganisms present in the 
urine should be isolated, and if it be the colon bacillus, acid sodium 
phosphate (NaH 2 Po 4 H 2 0) in 10-grain (0.65) doses, dissolved in 
plenty of water, be given every two or three hours so as to make the 
urine acid, since more formaldehyde is liberated from the urotropin 
if the urine is kept acid and an acid urine is not favorable to the 
growth of the colon bacillus. Indeed, it may be said that, unless the 
urine in the bladder is acid, enough formaldehyde is not set free to 
do any good. It is chiefly in the bladder and not in the kidneys that 
the drug is decomposed. Urotropin is largely employed to render the 
urine sterile in cases of typhoid fever and to act as an intestinal anti- 
septic. For the former purpose it is of great value not only in avoiding 
secondary vesical diseases, but in preventing the spread of typhoid 
fever to others. Investigations indicate that when large doses are 
given some of it is eliminated by the liver in the bile, and also by the 
walls of the gall-bladder and mucous membrane of the nose. For this 
reason its use in enteric fever to prevent cholecystitis is important. 
Crowe has also shown that it appears within an hour in the cerebro- 
spinal fluid, and although doubt has been thrown on this statement, 
in that the spinal fluid being alkaline does not set free formaldehyde, 
nevertheless it may be used in traumatisms of the brain and cord to 
prevent infection. Doses about double the ordinary amount are used 
for this purpose. 

In the presence of an epidemic of poliomyelitis it may be used as a 
prophylactic, or even with the hope that it may modify the disease 
when developed. Urotropin is also useful to abort acute coryza. 

In ordinary cases the dose is 10 to 30 grains (0.65-2.0), taken two 
or three times a day, dissolved in a half-pint of carbonated or plain 
water, but in some cases larger doses are needful. (See Helmitol.) 

Where a full effect is required smaller doses may be given five or six 
times a day, and it may be given in keratin-coated pills, since every 
grain altered by acid in the stomach produces that much less effect 
in the bladder. The continued use of large doses has resulted in 
hematuria and strangury. 

HOFFMANN'S ANODYNE. 

Spiritus Mtheris Compositus, B. P., consists of alcohol, ether, and 
the heavy oil of wine. It is no longer official in the U. S. P., but 
is largely used. The writer has experimentally studied very thor- 
oughly the action of the last-named ingredient, and finds: 



HOLOCAINE 307 

First. That the belief in heavy oil of wine being the quieting agent 
in Hoffmann's anodyne is fallacious. 

Second. The calmative effects of this mixture depend largely on 
the ether, rather than on the oil. 

Therapeutics.— Hoffmann's anodyne is the best carminative that 
we possess for general use, and is one of the best remedies for singultus 
or hiccough. This effect is accomplished by the alcohol and ether 
acting as irritants or stimulants to the stomach and intestine, so that 
free peristalsis results. In angina pectoris this drug is often the best 
remedy we have during the attack. In the cardiac palpitation of 
tobacco-heart or in that arising from indigestion and in the nausea and 
depression seen after excessive smoking it is also very useful. 

In sudden collapse in infants the following may be used with 
advantage: 

1$ — Spiritus aetheris compositi, 
Spiritus ammoniae aromatici, 

Tincturae aurantii aa Tfl,x (0.65) 

Aquae camphorse f5J (4.0). — M. 

S. — Give at one dose in a little water. 

Hoffmann's anodyne should always be given in capsule or in cold 
water, preferably ice-cold, in order to prevent too rapid volatilization 
of the ether and consequent difficulty in swallowing the liquid. 

The dose is 1 to 2 drams (4.0-8.0) to an adult. The vapor of the 
ether is so irritating that the drug is difficult of administration to very 
young children. 

HOLOCAINE. 

Holocaine is a synthetic substance allied to phenacetine, which is 
almost insoluble in cold water, and which is therefore commonly 
employed in the form of the soluble hydrochloride. This salt is a 
white crystalline body, which is stable when brought in contact with 
many agents, but is readily decomposed by alkalies. Solutions of this 
preparation possess distinct antiseptic power, and therefore do not 
require boiling in order that they may be sterile. As the drug when 
in solution gradually loses its anesthetic power, it should be freshly 
dissolved each time it is needed. 

Holocaine is used as a local anesthetic for the eye in place of cocaine, 
usually in the strength of 1 per cent. Its effects begin in about fifteen 
seconds to one minute, and last about Rve to fifteen minutes. It does 
not dilate the pupil as does cocaine, nor does it affect intra- ocular ten- 
sion or roughen the corneal epithelium . Holocaine has not supplanted 
cocaine, but, for the reason just given, is useful in cases requiring 
anesthesia and yet at the same time suffering from keratitis or iritis. 
It does not cause primary ischemia or secondary hyperemia of the 
mucous membrane as does cocaine. 



308 DRUGS 

HOMATROPINE. 

Homatropine is an artificial alkaloid obtained by prolonged and 
gentle heating of a solution of equivalent quantities of tropine 1 and 
toluic acid in hydrochloric acid. The hydrobromide of homatropine 
(Homatropine Hydrobromidum, U. S. and B. P.) is a crystallizable salt 
of homatropine, soluble in 5.7 parts of distilled water. The B. P. 
recognizes discs of homatropine (Lamellae Homatropince). 

Hydrobromide of homatropine, properly applied by frequent instil- 
lations, is a reliable mydriatic when it is desired to correct anomalies 
of refraction in healthy eyes. Experience is not at hand to determine 
its value for this purpose in eyes affected with retinal-choroidal dis- 
turbance. Atropine and hyoscyamine are preferred under such 
circumstances, for the obvious reason that their prolonged action is 
desirable as a method of treatment. The danger of systemic disturb- 
ance from homatropine is remote, even when repeated instillations 
have been made, and its temporary action upon the pulse causes no 
inconvenience to the patient. Slight hyperemia of the conjunctiva 
almost invariably follows its use, but true conjunctivitis, if it occurs 
at all, must be excessively rare. According to the studies of de 
Schweinitz and the writer, the drug has a physiological action closely 
allied to that of atropine, from which it is derived. Homatropine 
mydriasis generally lasts from thirty-six to forty-eight hours, that of 
hyoscyamine eight to nine days, and that of atropine ten to twelve 
days. For the production of ordinary mydriasis the drug should be 
used in solution of the strength of 4 grains (0.25) to the ounce (30.0) 
of distilled water, which is to be dropped into the eye every five or 
ten minutes. As the drug is expensive only a few drams of the solu- 
tion of the strength named should be ordered for a patient. 

HONEY. 

Honey, or Mel, U. S., is the saccharine fluid deposited in combs by 
the honey-bee, or Apis mellifica. It is used in medicine to mask the 
taste of disagreeable medicines. When it is abstracted from a par- 
ticular variety of flowers, it frequently has the odor of the flowers, and 
when taken internally may even produce the physiological or poison- 
ous effects of the plant from which it is gathered. This accident 
occurs commonly in those parts of the country where the bees have had 
access to mountain laurel and similar plants. 

Therapeutics.— Honey mixed with water is used as a vehicle in 
gargles and to relieve cough and dryness of the mouth and fauces. When 
used as a gargle it very distinctly increases the secretion of the mucous 
membrane, and so relieves the congestion. 

Under the name of Oxymel the B. P. recognizes a mixture of 8 parts 
of honey, 1 of acetic acid, and 1 of water. This is generally used as a 

1 Tropine is a product obtained by splitting up atropine into tropine and tropic acid. 



HOPS 309 

vehicle for more active remedies in gargles or even for expectorant 
mixtures. Melted and strained honey, to which a small proportion 
of glycerin is added, is known as Mel Depuration, U. S. and B. P. 
There are also a honey of roses (Mel Rosce, U. S.) and a confection 
(Confectio Rosa, U. S.) used as vehicles for other drugs. Mel Boracis, 
B. P., is used for the same purposes and for stomatitis. 

The objection to the use of honey in vehicles for active medicines 
is the fact that it is apt to disorder the stomach. 

HOPE'S CAMPHOR MIXTURE. 

This is a mixture originally made with nitrous acid, but largely 
used at present with nitric acid, owing to the fact that nitrous acid 
is changed into nitric acid when water is added to it. The nitrous 
acid is, however, more efficacious than nitric acid in the serous or 
choleraic diarrheas which it is used to combat. The formula is as 
follows : 

1$ — Acidi nitrosi f 5j (4.0) 

Aquse camphorae f§viij (240.0) 

Et adde: 

Tincturae opii gtt. xl (2.6).— M. 

S. — One-fourth of this in water every three or four hours. 

HOPS. 

Humulus, U. S., is the strobiles of ordinary hops, or Humulus 
Iwpulus. These contain a liquid volatile alkaloid, lupuline, and a 
bitter principle, lupulinic acid. Much confusion has arisen in regard 
to the preparations of this drug, partly because humulus is the official 
name in the U. S. P. and lupulus in the B. P. This confusion has 
been increased by the fact that the alkaloid of hops is called lupuline, 
while the powder which is found on the strobiles is called lupulin. 
Hops possess so little power that all the preparations official in the 
U. S. P. of 1900 have been excluded in the present issue. 

Therapeutics.— Hops are used as antispasmodics and nervous seda- 
tives in cases of hysteria and nervousness. In priapism, vesical irrita- 
bility, and renal irritation they are of service. Even in delirium 
tremens they seem to be of value. For local application a hop poultice 
may be made by placing the powdered strobiles in the mass, and 
employed in this way they are a favorite domestic remedy for local 
painful inflammations. Hops have been used in the form of a hop 
pillow in nervous insomnia, but the soporific influence is largely 
imaginary or depends on the fumes of the alcohol with which the 
pillow is moistened. 

Administration.— The tincture is given in the dose of \ to 3 ounces 
(16.0-90.0). Lupulin (Lupulinum, B. P.), which is the powder 
found on the strobiles of hops, is given in the dose of 2 to 5 grains 
(0.12-0.3) or more; and the fluidextract in the dose of 30 to 120 



310 DRUGS 

minims (2.0-8.0). The preparations of the B. P. are the infusion, 
dose 1 to 2 fluidounces (30.0-60.0), and the tincture, dose § to 1 
fluidram (2.0-4.0). 

HYDRASTIS. 

Hydrastis, U. S., or Hydrastis Rhizoma, B. P., is the dried rhizome 
and root of Hydrastis canadensis, sometimes called golden seal, 
containing two alkaloids known as hydrastine and berberine, and, 
perhaps, xanthopuccin. It should yield not less than 2.5 per cent, of 
hydrastine. 

Physiological Action.— When given to one of the lower animals in 
poisonous doses hydrastis may cause spinal convulsions followed by 
paralysis, according to the quantity of berberine or hydrastine present. 
The latter is more convulsive in its effects than the former. Upon 
the circulation hydrastine, when injected into the jugular vein, causes 
a primary fall of arterial pressure, succeeded by a decided rise, and 
the studies of Cerna have proved that it is an active poison. When 
given to man in medicinal amounts its effect on vital functions is very 
slight indeed. 

Therapeutics.— Hydrastis is of service in chronic g astro-intestinal 
catarrh, particularly that following the abuse of alcohol, and may be 
used as a stomachic and tonic after malarial fever and similar depress- 
ing diseases. Wherever mucous membranes are in a condition of 
lowered tone this drug is indicated. Thus in catarrhal jaundice of a 
subacute type, in uterine catarrh, in leucorrhea dependent upon a 
relaxed state of the vagina, and in chronic nasal inflammations and 
irritations it will be found useful. 

Tincture of hydrastis is said to possess a distinct antimalarial influ- 
ence, but this is doubtful. 

One of the best remedial measures that we have in the later stages 
of gonorrhea, when the acute period has passed, is the local and inter- 
nal use of hydrastis. If it is used as an injection, 5 grains (0.3) of the 
commercial hydrastine to each ounce (30.0) of water should be 
employed twice a day. Belfield has highly recommended the follow- 
ing formula for use in this disease prior to the tenth day: 

I& — Hydrastinse hydro chloridi gr. v (0.3) 

Protargol gr. v (0.3) 

Glycerini f3ss (2.0) 

Aquae destiUatse q. s. ad fBj (30.0).— M. 

S. — Precede with a hot-water injection and use four to six times daily, telling the 
patient to retain it five to ten minutes each time. 

The following infusion will be found of service in vaginal gonorrhea 
and leucorrhea: Take 1 dram of the powdered root and add it to 
8 ounces of boiling water; ^ to 1 dram of the fluidextract may also be 
added to a pint of water and used as a douche. 

Administration.— The fluidextract (Fluidextractum Hydrastis, U. S.; 
Extractum Hydrastis Liquidum, B. P.) may be given in the dose of 



HYDROCHLORIC ACID 311 

5 to 30 minims (0.3-2.0) and it should contain not less than 2.0 grams 
of hydrastine in each 100 cc. The dose of the tincture (Tinctura 
Hydrastis, U. S. and B. P.) is from 30 minims to 2 drams (2.0-8.0), 
and it should contain 0.4 grams of hydrastine in each 100 cc. The 
Glyceritum Hydrastis, U. S., is used as a healing application to mucous 
membranes. Extractum Hydrastis, U. S., is given in the dose of 1 
grain (0.06). 

Much doubt exists as to the dose of hydrastine. This arises from 
the fact that two forms of it are sold. That most commonly seen is 
a dark-brown mass which is very impure, and contains berberine 
and other substances. Its dose of this is 3 to 10 grains (0.2-0.6). 
The pure hydrastine (Hydrastina, U. S.), as made by Merck, is given 
in the dose of \ to J grain (0.015-0.03). Hydrastinine hydrochloride 
(Hydrastince hydrochloridum, U. S.) an artificial alkaloid of hydras- 
tine, dose J to 1 grain (0.03-0.06). 

HYDRIODIC ACID. 

Acidum Hydriodicum Dilutum (U. S. and B. P.) is a solution of 
hydriodic acid containing not less than 10 per cent, of absolute acid 
and about 90 per cent, of water. It should be kept in amber-colored 
glass-stoppered bottles and be protected from light. 

Its physiological and therapeutic action is practically identical with 
the other iodides (which see). If discolored, due to free iodine, it 
should be discarded. The dose is 5 to 40 minims (0.3-2.6), well 
diluted with water. 

The syrup of hydriodic acid (Syrupus Acidi Hydriodici, U. S. and 
B. P.), containing 1 part of dilute hydriodic acid to 3 of water and 

6 of syrup, is the preparation commonly employed, and it is an efficient 
substitute for the other iodides. The dose is from 1 to 4 drams (4.0- 
16.0), well diluted with water, and taken one hour after meals. 

HYDROBROMIC ACID. 

(See Bromides.) 

HYDROCHLORIC ACID. 

Acidum Hydrochbricum (U. S. and B. P.) is a clear, colorless liquid, 
possessing an acid odor and taste, devoid of astringency, but in 
concentrated form decidedly caustic. It should be kept in dark- 
colored bottles. In the strength of 0.2 per cent, it is normally present 
in the gastric juice, and aids the pepsin in the conversion of proteids 
into peptones and in the formation of pepsin from pepsinogen. 

Therapeutics.— Hydrochloric acid is indicated only in certain forms 
of indigestion. With new methods of studying gastric secretions we 
have learned that it is of value in those cases in which the gastric 



312 DRUGS 

secretion of HC1 is deficient. Thus it is given to aid digestion during 
and after fevers, when this acid is apt to be absent from the gastric 
juice, particularly in typhoid fever. In cases of gastric cancer, when 
this acid is usually absent from the gastric secretion, and in the sick 
stomach following an alcoholic debauch, it is of great service. In 
some cases of chronic gastric catarrh with dilatation, in which there is 
atrophy of the gastric tubules, it should be used freely. The dose of 
the dilute acid (Acidum Hydrochloricum Dilutum, U. S. and B. P.) is 
5 to 20 minims (0.30-1.3). (See Indigestion, Part IV.) 
A useful prescription in such cases is: 

Ifc— Acidi hydrochlorici diluti f^ij (8.0) 

Essentise pepsini f5j (30.0) 

Tincturae gentianae compositse . . . q. s. ad f 5iv (120.0). — M. 

S. — Dessertspoonful (8.0) in a little water with meals. 

This acid is combined with nitric acid to form dilute nitro-hydro- 
chloric acid (Acidum Nitro-hydrochloricum Dilutum, U. S. and B. P.) 
the dose of which is 10 to 30 minims (0.6^.0), 5 to 20 minims (0.3-1.3), 
B. P.; also the pure acid (Acidum Nitro-hydrochloricum, U. S.), dose 
1 to 5 minims (0.05-0.3). 

Hydrochloric acid causes, when taken in poisonous doses, violent 
g astro-enteritis and corrosion of the gastric walls, and its action should 
be combated by alkalies, soap, oils, and white of egg, and the use of 
opium to relieve pain and irritation. 

HYDROCYANIC ACID. 

Hydrocyanic or Prussic Acid is a transparent, colorless, very vola- 
tile liquid, giving rise to vertigo when inhaled in minute amounts and 
capable of producing death if the fumes be concentrated. If the 
bottle containing the pure drug be opened, it should be done where 
there is sufficient draught between windows to prevent any contamina- 
tion of the atmosphere of the room by the acid. 

Pure hydrocyanic acid is never used in medicine; the form employed 
is the dilute acid (Acidum Hydrocyanicum Dilutum, U. S. and B. P.), 
which contains about 2 per cent, of the drug in water. It must be 
kept in dark, tightly-stoppered bottles. 

Physiological Action.— This is one of the most rapid (if not the most 
rapid) of the lethal poisons, only being approached by carbolic acid 
and nitrobenzole in the violence of its effects. Owing to its volatility, 
it is absorbed with great rapidity, and acts upon the respiratory 
center and the heart, being eliminated almost immediately afterward. 
Because of its fleeting character, the survival of a patient twenty or 
thirty minutes after the ingestion of a poisonous dose is a favorable 
sign for his recovery. 

The drug is an active paralyzant and exerts a lethal influence over 
every part of the body. The nervous system, heart, respiration, 
brain, and all vital parts are killed at once if much of it is present. 



HYDROCYANIC ACID 



313 



Poisoning.— When a lethal dose of hydrocyanic acid is taken, death 
either comes at once, so that the person drops with a gasp, is for a 
moment convulsed, the face cyanotic, the eyes wide open, with the 
teeth tightly clinched, and the lips covered by a bloody froth, or three 
stages of poisoning may ensue if the dose has not been large enough to 
result in immediate death, owing to its slow absorption. In the first 
of these stages there are difficult respiration, slow cardiac action, and 
disturbed cerebration. In the second stage, which is convulsive, 
there are present wild cries, dilated pupils, unconsciousness, vomiting, 
spasmodic urination and defecation, erections of the penis, and ejacu- 
lations of semen. In the third stage there are asphyxia, collapse, and 
paralysis ending in death. The blood is found to be dark and venous- 
looking, but does not give the spectrum bands of cyanohemoglobin. 
These bands only appear when the drug is shaken with blood outside 
the body. 




Fig. 50. — Tracing of the deep stormy respirations of an animal under the influence 
of hydrocyanic acid. (After Schmiedeberg.) I, normal respirations; II, acid inhaled ; 
III, violent deep respirations; IV, arrest of respiration. 



The diagnostic signs of death from prussic acid are the odor of the 
acid about the body, the wide-staring eye, the clinched teeth covered 
with froth, and the livid, cyanosed face. If the body be opened, the 
odor of hydrocyanic acid is marked, but this rapidly passes away 
owing to the volatility of the drug. 

The only poison producing symptoms resembling those which have 
just been described is nitrobenzole, or essence of mirbane, which has 
a somewhat similar odor, but which is, however, more permanent, the 
odor remaining for hours in the opened body. 

Therapeutics.— Hydrocyanic acid is used in cases of gastralgia of 
purely nervous origin, in some cases of nervous vomiting, and in 
irritable stomach, where owing to hyperesthesia of the mucous mem- 
branes, the taking of food produces discomfort. 

In irritable coughs, due to tickling in the throat and bronchi, it is 
very extensively used, and has received high praise by those best 
qualified to judge. On the other hand, it has been claimed that owing 
to the extreme volatility of the drug it acts only for the moment, and 
that a dose every ten or fifteen minutes is necessary to produce any 
constant effect. However this may be in theory, practically the acid 



314 DRUGS 

certainly does aid in relieving cough. In these states the following 
prescription will be found of service: 

I^ — Acidi hydrocyanici diluti f5j (4.0) 

Syrupi pruni virginianse f5iij (90.0). — M. 

S. — Teaspoonful (4.0) every four or five hours to an adult. 

In enteralgia or neuralgia of the intestine dilute prussic acid is 
often a useful remedy. 

Externally, the drug is useful in pruritus and other forms of itching 
skin diseases, and the following formula will be found of service in 
pruritus vulva?: 

]$ — Hydrargyri chloridi corrosivi gr. iss (0.09) 

Acidi hydrocyanici diluti f 3 J (4.0) 

Aquae amygdalae amarae f ovj (180.0). — M. 

S. — Poison! For external use. Apply to the itching surface with a small rag. 

The same prescription may also be employed in pruritus without 
the bichloride, if so desired. The dose of dilute hydrocyanic acid is 
1 to 5 minims (0.05-0.3) . In certain forms of irritable cough inhala- 
tions of the vapor (Vapor Acidi Hydrocyanici) are recommended; 
this is prepared by adding 10 to 15 minims (0.6-1.0) of the diluted 
acid to 1 fluidram (4.0) of water, which is then placed in a suitable 
apparatus, from which is inhaled the vapor that arises. 



HYDROGEN PEROXIDE. 

Peroxide of hydrogen is a clear, odorless, syrupy fluid of a specific 
gravity of 1.452, possessing a harsh, bitter taste. It is readily soluble 
in water, and its chemical formula is H 2 2 . Pure peroxide of hydrogen 
is never used in medicine, but in solutions of varying strength. The 
ordinary solution, as found in the shops and that now official (Liquor 
Hydrogenii Dioxidi, U. S., Liquor Hydrogenii Peroxidi, B. P.), is 
a slightly acid, aqueous solution of hydrogen dioxide, which should 
contain, when freshly prepared, about 3 per cent., by weight, of 
absolute hydrogen dioxide, corresponding to about 10 volumes of 
available oxygen. It should be kept in a cool place. Upon removing 
the stopper from the bottle not more than a slight pressure should be 
observed. It is a colorless liquid, liable to deteriorate upon keeping 
or on protracted agitation, without odor, slightly acidulous to the 
taste, and producing a peculiar sensation and soapy froth in the 
mouth. If the stopper in the bottle be replaced by a pledget of 
cotton, deterioration is retarded. When exposed to the air at the 
ordinary temperature, or when heated on a water-bath at a tempera- 
ture not exceeding 60° C. (140° F.), the solution loses chiefly water. 
When rapidly heated, it frequently decomposes suddenly. The term 
"10 volumes" signifies that it can yield 10 volumes of available 
oxygen, and it is upon this yield of oxygen that its activity depends. 
The acid reaction is due to a small amount of acid added to the 



HYDROGEN PEROXIDE 315 

solution to preserve it. This can be neutralized by the addition of a 
little sodium bicarbonate just before it is used. The official solution 
of peroxide of hydrogen, while the most stable that can be prepared, 
is nevertheless readily deteriorated by exposure to heat, sunlight, or 
prolonged shaking. If placed in an absolutely clean, smooth glass 
vessel it may be concentrated for immediate use by exposing it to a 
temperature of 140° F.; but exposure to a temperature above this 
point may result in its decomposition with explosive violence. Practi- 
cally, this means of concentration is not convenient for the practi- 
tioner, and the ordinary official solution fulfils all ordinary require- 
ments unless it has deteriorated by age. The great difficulty in the 
use of the solution of the peroxide is its liability to undergo a change 
and become practically worthless. Wallian stated that as a rough 
test for the value of a given solution a few crystals of permanganate 
of potassium may be placed in a test-tube, and 1 to 2 drams (4.0- 
8.0) of the solution added. The violence of the resulting effervescence 
is in direct ratio to its value as a remedial agent. Marshall has 
proved that the constituent of blood and pus that sets free the oxygen 
from this drug is globulin. 

Therapeutics.— The most valuable use of the peroxide of hydrogen 
solution in medicine is in the treatment of diphtheria. So far as we 
know, it is the best application for the destruction and removal of the 
false membrane. There is no injury to the normal tissues nor is there 
the danger of poisoning which sometimes follows the use of such drugs 
as carbolic acid. Applied to the false membrane, there is at once an 
active effervescence with some local tingling of the part. The mem- 
brane can afterward be removed in shreds. The solution should 
be applied by means of a swab or spray, but if the latter is used a 
glass atomizer must be employed, as the peroxide is decomposed by 
coming in contact with metals. Peroxide of hydrogen is also a very 
valuable application for cases of follicular tonsillitis with profuse 
exudation, to cleanse the parts prior to the use of guaiacol. (See 
Guaiacol.) 

In the treatment of abscess cavities, tubercular or septic in character, 
the peroxide of hydrogen is a very valuable application, and its use 
will often decide the presence of pus, since when it meets with this 
material active effervescence ensues; but care must be exercised that 
free vent is allowed for the gas that is given off, as if confined it will 
force the septic material into the surrounding healthy tissues. Simi- 
larly, it is a valuable preparation for cleansing infected wounds, ulcers, 
and malignant growths which have ulcerated. 

Hydrogen peroxide is a useful agent for the removal of powder- 
stains in recent cases. 

It is stated that the application of this liquid to the spot affected 
by a hornet's sting will give instant relief; and applied by means of 
an atomizer it is the best fluid to aid in the painless removal of adhesive 
strips. The part of the strip next to the skin should be sprayed 



316 DRUGS 

as it is gradually pulled off. It is also used on plaster-of-Paris dress- 
ings to soften the material so that it can be cut with a knife or shears. 

Where the peroxide is used as a gargle or mouth-wash it may pro- 
duce pain through its attacking cavities in the teeth or the metallic 
substances with which they are filled. When so used it should always 
be diluted, 1 part to 3 of water. 

The employment of the peroxide internally, with the idea that it 
will yield oxygen to the body in cases in which this gas is lacking in 
the blood, is futile. Even if the oxygen entered the blood, the amount 
disengaged from a possible dose would be too small to be of value. 

Taken internally the peroxide of hydrogen is not poisonous. The 
internal dose of the Liquor Hydrogenii Dioxidi of the U. S. P. is from 
1 to 4 drams (4.0-16.0), well diluted with water, and taken from a 
porcelain, not a metal, cup or spoon. It possesses no distinct value 
in internal medication. 

HYOSCYAMUS. 

Hyoscyamus, U. S., or henbane, is a plant of the Northern United 
States and Europe. It is the dried leaves and flowering tops of Hyos- 
cyamus niger, collected from plants of the second year's growth, and 
should contain not less than 0.08 per cent, of mydriatic alkaloids. 
The leaves (Hyoscyami Foli B. P.), only are used, and from them are 
obtained two alkaloids— one known as hyoscy amine, the other as 
hyoscine. (See Hyoscine.) The first has practically the same phy- 
siological action as atropine, save that it is more sedative in its effects 
on the nervous system. (See Belladonna.) The second is quite dif- 
ferent in its influence over the body. The only marked difference in 
the action of hyoscyamine and atropine upon the eye is in the 
mydriasis produced by each. While that of atropine lasts, in man, 
from twelve to fourteen days, hyoscyamine generally remains for 
only seven to nine days. Sometimes the development of mydriasis 
is preceded by violent pain in the eye due to a cramp of the ciliary 
muscle. If so, the drug must be pushed to overcome the spasm. 
The strength of the solution to be used is 2 grains (0.12) to the ounce 
(30.0). Owing to the presence of hyoscine in hyoscyamus, it is more 
quieting and depressing to the nervous system than is belladonna. 

Therapeutics.— Hyoscyamus is used in every condition indicating 
the employment of belladonna; or, in other words, wherever local 
spasm or arterial relaxation exists or where pain is due to spasm. It 
has been particularly recommended in nervous cough, in whooping- 
cough, and in colic, and probably is better in its influences in these 
states than is belladonna. In combination with nitrate of silver the 
extract may be used with advantage in chronic gastric catarrh and 
gastric ulcer. In urinary incontinence due to irritable bladder it is very 
serviceable, and particularly, is this true of this affection in children 
and old persons, provided that the urine is first rendered normal by 



HYOSCYAMUS 317 

the use of acidifying drugs or by the use of alkalinizing drugs if it is 
abnormally acid. 

Administration.— The drug itself is official in four forms and as 
hyoscy amine sulphate and hydrobromide. The dose of the tincture 
(Tinctura Hyoscy ami, U. S. and B. P.) is 10 to 40 minims (0.6-2.6), 
\ to 1 fluidram (2.0-4.0), B. P., and should contain 0.007 gram of 
mydriatic alkaloids in 100 cc; the alcoholic extract (Extraction Hyo- 
scy ami, U. S. and B. P.), dose \ to 1 grain (0.03-0.06), 2 to 8 grains 
(0.12-0.48), B. P., should contain 0.3 per cent, of total alkaloids; 
the alkaloid (Hyoscyamina? Hydrobromidum, U. S.), dose -gV to -^ 
grain (0.001-0.0015), y^ to ^ grain (0.0003-0.0006), B. P.; the 
fluidextract (Fluidextractum Hyoscyami, U. S.) contains 0.075 gram 
of alkaloids in each 100 cc, and is given in the dose of from 2 to 10 
minims (0.10-0.60). 

Hyoscine. 

This is one of the alkaloids derived from hyoscyamus, and is a thick 
syrupy substance which forms a crystalline salt with an acid. It has 
been largely supplanted by scopolamine, to which the name Hyoscine 
has been given. Some clinicians claim that although these alkaloids 
are chemically identical their therapeutic effect is different. (See 
Scopolamine.) 

Hyoscine is official in the form of Scopolamine Hydrobromide 
(Scopolamine Hydrobromidum, U. S. and B. P.). 

Physiological Action.— Hyoscine quiets the cerebrum and produces 
deep sleep in a certain class of patients. In the lower animals or in 
man it may cause sleep or wild delirium. It causes loss of reflex action 
in overdose, which is due to depression of the spinal cord and not of 
the nerve-trunks. Upon the circulation it has little effect, but it is 
worthy of note that it influences the vagus nerves, as does atropine, 
stimulating them at first, but finally depressing them, although the 
contrary has been asserted. In any event, the circulatory effect is a 
minor one. 

In cases where hyoscine has acted in excess, or where an overdose 
has been given, pilocarpine may be used as a physiological antidote 
in full doses if the heart is sound. 

Therapeutics.— Hyoscine is of value as a hypnotic in a very limited 
class of cases, and in this class generally acts most favorably. These 
cases consist of those who, from acute mania, hysteria, or similar cause, 
suffer from insomnia, and perhaps struggle violently against proper 
control or refuse to swallow or retain food. 

The drug may be given to such persons hypodermically, in the 
dose of yxro to ^o- grain (0.0006), or by the mouth in the dose of -^ to 
sV grain (0.0008). The fact that it possesses no taste and is small in 
bulk renders it readily employed. In some persons it utterly fails, 
even in this particular type of case. In delirium tremens it may cause 
evidences of cerebral congestion and Cheyne-Stokes breathing, but, 



318 DRUGS 

on the other hand, it very commonly aids in combating chronic alco- 
holism when given in very large dose. (See below.) Some patients 
are not quieted by the drug, but pace up and down in a semi-sane 
condition until its action wears off. Such symptoms can generally be 
overcome by using larger doses or, better still, by using with it -^j- 
grain of apomorphine. It does badly if the kidneys are diseased. 

Hyoscine has been highly recommended in the treatment of the 
morphine and alcohol habit, and there can be no doubt that it is an 
excellent remedy. The patient must be under complete control and 
should be given enough hyoscine hypodermically to be thoroughly 
under its influence, as much as y J -$■ grain being given every two hours 
if need be to keep him quiet. Aside from constant quiet muttering 
and the characteristic delirium caused by the drug, no evil effects 
ensue and the patient usually, without much suffering, recovers from 
the effects of the narcotic drug to which he is a slave, and in a good 
general state so far as his nerves are concerned. (See Alcohol.) 

Hyoscine is of great value in some cases of spermatorrhea and noc- 
turnal emissions if given in the dose of tw~o grain (0.0006) at bed-time. 

The drug is contraindicated in the sore-throat of scarlet fever, as 
it may cause a sensation of pharyngeal constriction. In the insomnia 
of heart disease with nervousness it may cause sleep, but often fails, 
and is not to be recommended. 

Hyoscine is used by ophthalmic surgeons, and in the eye it is far 
less irritating than atropine. Indeed, it may be considered as being 
distinctly sedative in plastic iritis. Its effects are not, however, so 
lasting as are those of atropine; y^~o grain dropped into the eye in one 
dose produces mydriasis in eighteen minutes and ciliary paralysis in 
twenty-three minutes; this mydriasis lasts about twenty-two hours, 
and the ciliary paralysis about ninety-six hours (Oliver). It finds 
its greatest usefulness in the early stages of iritis, when a rapidly 
acting and efficient sedative mydriatic is demanded. Hyoscine is best 
used for this purpose in the strength of 0.2 per cent. (1 : 500) in water. 
This solution may be dropped into the eye every twenty minutes till 
one hour has elapsed. As this use of the drug is slightly painful it 
is well to place a few drops of cocaine solution in the eye before each 
instillation of hyoscine. 

ICHTHYOL. 

The substance sold in the shops and employed in medicine under 
the name of ichthyol is a salt formed by the bibasic acid ichthyo- 
sulphuric or sulpho-ichthyolic acid with ammonium. In other words, 
it is ammonium ichthyol, which is a semi-solid substance. The 
ichthyo-sulphuric acid itself is derived from a crude oil, which in 
turn is obtained by destructive distillation from a deposit of fossil fish 
found in the Tyrol Mountains. When combined with sodium forming 
sodium ichthyol, a more solid substance than ammonium ichthyol is 
formed which can be employed if it is desired to use the drug in pill 



ICHTHYOL 319 

form. Both the ammonium and sodium ichthyol contain about 10 
per cent, of sulphur, and it is largely upon this that their therapeutic 
activity depends. They are both soluble in water, and have a dark- 
brown, tarry appearance. Their disagreeable odor is due to an 
inseparable volatile oil. The stain produced by ichthyol is easily 
washed out of ordinary clothing except when it is mixed with vaseline, 
which, being insoluble in water, fixes the stain in the fabric. 

Therapeutics.— Ichthyol is, without doubt, one of the most remark- 
able substances introduced for medicinal purposes within the last 
thirty years, both because of its curious origin and its therapeutic 
value in a large variety of ailments. In the author's hands it has 
proved most efficacious in the treatment of the inflamed areas in 
acute articular rheumatism. When used in this disease an ointment 
composed as follows is to be smeared over the inflamed part, and then 
spread on lint, which is wrapped about the limb : 

3— Ichthyolis Sss (16.0) 

Olei citronellae gtt. xvvelxxx (1.0-2.0) 

Adipis vel adipis lanse hydrosi . . . . 5j (30.0). — M. 

This usually relieves the pain and tenderness of the part to a great 
extent. The same application, accompanied by rubbing or applying 
massage to the joint, is of value for the pain and stiffness met with 
after the acute manifestations of the disease has passed by. 

The same prescription is also the best external treatment of erysip- 
elas that we have. The skin should be carefully and gently washed, 
and then anointed with the ointment and covered by lint smeared 
with this ointment. If the disease be in the skin of the face, holes are 
to be cut in the lint for the mouth, nose, and eyes. Ichthyol is also a 
very useful drug in the treatment of chronic skin diseases associated 
with atony and induration of the deeper layers of the skin, such as 
acne, eczema, and lupus and keloid in their chronic stages. It is 
always better to use ichthyol in ointment form, but some practitioners 
have employed it by painting it on in watery solution with a camel' s- 
hair brush. In frost-bites, chilblains, and in burns it is of service, and 
Agnew recommended it highly when rubbed into lymphatic enlarge- 
ments. Ichthyol has proved remarkably efficacious in removing peri- 
uterine and other pelvic exudations when used as a salve with pelvic 
massage or in a vaginal suppository. 

For acute sprains, and for the removal of the swelling following 
such injuries, its influence is extraordinary if it be well rubbed into 
the part affected. 

In severe cases of cracked nipples, with much induration, an oint- 
ment of ichthyol, 1 to 4 drams (4.0-16.0) of lanolin, will prove of 
value, but it must be washed off thoroughly before each nursing or 
the child will not take the breast. Often the odor remains and pre- 
vents nursing. 



320 DRUGS 

The dose of ichthyol internally in g astro-intestinal catarrh is 1 to 10 
grains (0.06-0.6), given in pill or capsule. 

Ichthyol is a very useful remedy for the treatment of fetid ozena. 
(See Nasal Catarrah, Atrophic, Part IV.) 

IODALBIN. 

Iodalbin is a new iodine preparation containing about 20 per cent, 
of iodine, or. in other words, about 56 per cent, less iodine than iodide 
of potassium. It is used for the same purposes as the latter drug. 
Owing to the readiness with which the iodine is absorbed, doses larger 
than those of iodide of potassium are usually not required, or, to 
express it differently, the iodine does not separate from the iodide of 
potassium, sodium, or ammonium as readily as it does from this 
combination of iodine with a proteid. 

The minimum dose is 5 grains (0.3), repeated as frequently as may 
be needed. 

IODIDE OF AMMONIUM. 

(See Ammonium Iodide.) 

IODIDE OF POTASSIUM. 

Potassium iodide (Potassii Iodidum, U. S. and B. P.) should contain 
not less than 99 per cent, of pure potassium iodide, and should be 
kept in well-stoppered bottles. 

It occurs in colorless transparent, translucent, or opaque white, 
cubical crystals, or a white, granular powder, having a peculiar faint, 
iodine-like odor, and a pungent, saline, afterward bitter taste. It is 
permanent in dry air, and but slightly deliquescent in moist air. It 
is soluble in 0.7 part of water, and in about 22 parts of alcohol at 
25° C. (77° F.); in 0.5 part of boiling water, and in 8 parts of boiling 
alcohol; and in 2 parts of glycerin. 

The physiological effects of potassium iodide are entirely compar- 
able to those of iodine itself (see Iodine), but it is employed for some- 
what different purposes, is less irritant, more readily given, and per- 
haps more readily absorbed. When it is given in very large doses 
or for a long period of time, the fact that the potassium base is a 
depressant poison is to be remembered, and it is well to use iodide 
of sodium instead. (See Sodium Iodide.) 

Physiological Action.— Circulation.— Upon this part of the system 
when in health iodide of potassium produces effects differing very 
slightly, if at all, from those caused by potassium itself. Small 
amounts raise the blood-pressure, and large quantities lower it 
(Provost and Binet), but if spasm and fibrosis of the bloodvessels 
be present with high arterial tension in association with it, iodide of 
potassium acts as a valuable remedy in gradually reducing the vascular 
spasm. 



IODIDE OF POTASSIUM 321 

Absorption and Elimination.— Iodide of potassium is very rapidly 
absorbed and eliminated, appearing in the urine, according to Doux, 
in thirteen minutes after it is ingested, the daily amount excreted 
equalling about 80 per cent, of the dose taken. Some of the drug 
tends to accumulate in the body. It is evident, therefore, that in the 
use of iodide of potassium we should give it freely and frequently until 
the residual amount has reached its limit, when smaller doses may be 
given, and given less frequently, for the purpose of maintaining the 
iodine influence. That is to say, the drug should be given up to the 
point of tolerance, whatever that may be, and then a smaller dose will 
be sufficient to maintain its influence by replacing the albuminoid 
compounds of iodine as they are slowly eliminated. On the other 
hand, if the iodide is being given for the purpose of eliminating some 
poison, as lead, for example, here the dose cannot be greatly decreased, 
because in addition to the quantity ordinarily eliminated a portion is 
passed out as a double soluble iodide of lead. This theoretical deduc- 
tion seems to find support in the fact that after the syphilologist 
reaches the full effect of the drug he often cuts the dose down to what 
he calls the "tonic dose," and so maintains the constant alterative 
effect without disordering the functions of the body. If he does not 
do this, the drug accumulates and causes chronic iodine cachexia, a 
state which it is important to avoid in grave diseases like syphilis, 
which depend for their relief so largely on the maintenance of vitality 
in the patient. 

All traces of the iodine in the urine disappear four or five days after 
the last dose is administered (Elhers). 

Therapeutics.— The medicinal uses of iodide of potassium may be 
divided into three great divisions, each of which is important. It is 
also employed for many conditions not included in these classes : 

1. Syphilis.— The use of iodide of potassium in syphilis is recog- 
nized as a part of all treatment for its relief. Elsewhere, Dr. Martin, 
in his excellent article (see Syphilis), treats of this question, and it 
is only necessary to call attention to the fact that the drug is gener- 
ally well borne in large amounts by advanced syphilitics, although 
this is not always the case. The term "therapeutic test" is applied 
by one eminent teacher to signify a state of the system produced by 
syphilis in which a diagnosis may be made by the fact that large doses 
of the iodide are borne without inconvenience. This resistance does 
not always prove the presence of syphilis, nor does the absence of this 
resistance prove the absence of this disease. Persons having heredi- 
tary asthma, gout, rheumatism, or some similar diathetic malady often 
resist the iodide, and, on the other hand, some syphilitics exhibit 
"iodism" after very small doses. In treating late syphilis the drug 
should be used in the dose of 10 grains (0.60) three times a day, and 
this amount gradually increased a grain a day until symptoms of 
"iodism" occur. 

It is well to bear in mind that non-syphilitic persons who are 
21 



322 DRUGS 

taking, or have recently taken, iodides often give a positive reaction 
to the luetin test. 

The quantity borne often amounts to from 100 to 200 grains (6.6- 
13.2) a day, and as much as 400 grains may be taken by some persons. 
The best way to use the iodide of potassium is to order for the patient 
a saturated solution of the drug, which contains in each drop about 
1 grain, and at the same time a bottle of the compound syrup of 
sarsaparilla. To a tablespoonful of the latter the patient is to add the 
iodide solution, beginning with 10 minims (0.6) three times a day, 
and increasing a minim every dose each twenty-four hours. 

The iodide acts more slowly as an antisyphilitic than does mercury. 

In tertiary syphilis the iodide is often valuable rather to hold the 
pathological process in check than to affect the specific cause. 

In nervous syphilis, be its manifestations what they may, iodide of 
potassium is a standard remedy, but mercury and arsphenamine are 
more active and useful in the early stages. It is not curative in 
sclerotic post-syphilitic changes nor in locomotor ataxia due to 
syphilis, except in the earliest stages, because destroyed cells cannot 
be restored, but it can be used to arrest further advance of the results 
of the disease. It may greatly improve the patient's condition by 
preserving cells not as yet entirely destroyed. 

The therapeutic effect of this drug is much increased if hot vapor 
baths are used simultaneously with its internal administration. 

2. Metallic Poisoning.— Owing to the fact that iodide of potas- 
sium forms soluble double salts with all the metals in the tissues in 
chronic poisoning, thereby aiding in their elimination, it should always 
be employed in chronic lead, zinc, arsenic, or mercurial poisoning. 

3. Antirheumatic— Iodide of potassium is best suited, not to 
acute articular rheumatism, when the joints are very hot and painful, 
but to the secondary or subacute types, when the joints are enlarged 
and the case " hangs on"— now better, now worse. It acts well, under 
these circumstances, if combined with wine of colchicum-seed. (See 
Rheumatism.) It is also to be tried in sciatica, lumbago, and rheu- 
matic neuralgia, and it may be employed in chronic pleurisy, peri- 
carditis, and hydrocephalus to cause absorption of the fluids. In these 
conditions, however, it often fails and cannot be relied upon. 

In aneurism, particularly that of the aorta, the drug often does good, 
but its value rests largely upon the cause of the disease. If it is due to 
syphilis, the aneurism may cease to grow under its influence, and the 
pain, swelling, and pulsation gradually decrease. 

In asthma iodide of potassium is valuable if the disease is of the pure 
bronchial or lithemic type, but it ought not to be employed if the cause 
is associated with gastric irritation or indigestion, as it makes the 
condition of the stomach worse. In bronchitis and intestinal catarrh 
where the condition of the mucous membranes is semi-chronic, and 
not relieved by chloride of ammonium, iodide of potassium should be 
used. If the bronchitis is chronic and the secretion profuse (bron- 



IODIDE OF POTASSIUM 323 

chorrhea), iodide of potassium will make it worse. The dose for an 
adult in all these instances should be about 3 to 5 grains (0.2-0.3) 
three times a day, for small doses tend to increase secretion far more 
than large ones, which often seem to decrease it. In pulmonary 
emphysema iodide of potassium is often of great value chiefly because 
it benefits the associated chronic bronchitis. 

In chronic interstitial nephritis small doses (5 grains [0.3] t. i. d.) 
are thought by some to check the disease, but it is to be remembered 
that the drug may produce untoward symptoms if the kidneys do not 
eliminate it, so that, if used at all, it must be given with great care. If 
the drug is well borne in chronic parenchymatous nephritis, it will 
cause an extraordinary increase in the urinary flow, and will often 
relieve very rapidly any dropsy which may be present. 

In true goiter the employment of iodide of potassium internally and 
tincture of iodine externally is the best medical treatment we can use, 
and in acute coryza, or " cold in the head," 10 grains (0.6) taken at the 
beginning of the trouble will often abort the attack. 

In hepatic cirrhosis, in its early stages, the iodide often does good 
in arresting the overgrowth of connective tissue, and in arteriosclerosis 
or atheroma of the bloodvessels it is of great service. Thus in the 
latter conditions a combination of iodide of sodium or potassium 
with a little digitalis will relieve vascular spasm and support a feeble 
heart. 

A very important use of iodide of potassium is for the removal of 
enlargements of the cervical glands and those occurring in other parts 
of the body. Full doses are useful in actinomycosis. In the later 
stages of pneumonia the iodides are sometimes useful to aid in the 
absorption of the exudate, but they are contraindicated in phthisis, 
except in the fibroid form and except in those cases which are 
dependent upon syphilis as an underlying dyscrasia, as they aid in 
the breaking down of the lung. 

Untoward Effects.— In some persons, after the use of the iodide, 
coryza comes on, so that the edges of the eyelids become reddened 
and the nose runs constantly; and it is a curious fact that small 
doses are more apt to produce such a result than large ones. This is 
followed, if the drug is freely given, by the more positive signs of 
"iodism" spoken of under Iodine. 

In other cases acne breaks out on the face and disorders of digestion 
and gastric irritability come on. The acne can nearly always be pre- 
vented by giving arsenic at the same time with the iodide. In some 
cases petechial rashes break out on the legs, while in others great 
mental and physical depression appears, so that listlessness or melan- 
cholia may develop. Sometimes iodide of potassium causes diarrhea. 

In persons susceptible to iodide of potassium care should be exer- 
cised when it is first administered lest sudden and dangerous edema 
of the glottis occur. Eisner has reported a case in which death due 
to this cause followed the administration of 30 grains of the iodide 



324 DRUGS 

of potassium. Multiple hemorrhages from the skin and mucous 
membrane occurred. 

If bullae or blebs follow the use of the iodides or other rashes appear, 
it is said that atropine will afford relief. 

Sometimes the iodide of ammonium or iodide of sodium or iodide 
of strontium will be borne when the iodide of potassium will not. 

The hydrochloric acid and chloroform test for indoxyl sulphate of 
potassium in the urine is useless if the patient is taking iodides. 

Administration. —The iodide of potassium, owing to its exceed- 
ingly disagreeable taste, should be given with the compound syrup 
of sarsaparilla, as already described, with fluidextract of liquorice, or 
in milk. Large amounts of these vehicles are to be used. A good 
way to give it is to add the drug to one of the liquid pepsins, and then 
to add this to warm milk, as in the directions for the preparations of 
junket given in Part III. The curd largely disguises the taste of the 
drug. The dose usually varies from 5 to 60 grains (0.3-4.0) three 
times a day, according to the condition of the patient. It is best given 
an hour after meals, so that it will not disorder digestion by irritating 
the stomach or interfere with the action of the gastric juice. 

One of the best ways to take the drug is in capsule, but if this is done 
a drink of milk or water or other fluid should precede or follow it, in 
order to prevent the drug from coming in contact with the stomach 
in concentrated form. 

IODIDE OF SODIUM. 

Sodii Iodidum, U. S. and B. P., is used in the same doses and for the 
same purposes as the iodide of potassium, and is less irritant than the 
latter salt, as well as less depressant to the general system. 

IODIDE OF STRONTIUM. 

Iodide of strontium (Strontii Iodidum, U. S.) is used as a substitute 
for iodide of potassium, as it is less irritating to the stomach and less 
depressing to the general system. (See Strontium.) 

IODINE. 

Iodum, U. S. and B. P., is a non-metallic element found largely in 
seaweed and in mineral iodates and iodides. It should contain not 
less than 99 per cent, of pure iodine, and be kept in glass-stoppered 
bottles, in a cool place. It occurs as heavy, bluish-black, dry and 
friable, rhombic plates, having a metallic luster, a distinctive odor, 
and a sharp and acrid taste. 

Iodine imparts a deep brown, evanescent stain to the skin, and 
slowly destroys vegetable colors. It is soluble in about 2950 parts of 
water, and in 12.2 parts of alcohol at 25° C. (77° F.). It is freely 
soluble in ether, chloroform, or carbon disulphide ; its solution in alco- 



IODINE 325 

hoi or in an aqueous solution of potassium iodide has a reddish color; 
its solution in chloroform or carbon disulphide has a violet color. 

It volatilizes slowly at ordinary temperatures. 

Physiological Action.— The physiological action of iodine, so far as 
its alterative powers are concerned, is absolutely unknown. Applied 
to the skin, it stains it yellow, brown, or black according to the free- 
dom of its application, and it acts without pain if the skin is intact. 
If very large amounts are used, it produces vesication. Upon mucous 
membranes iodine acts as a powerful irritant. Germain-See believed 
it to be a stimulant to the nutritive processes of the body and to the 
circulatory system, and he was certainly correct in regard to the 
influence it exercises over nutrition. 

Absorption and Elimination.— The drug is rapidly absorbed, 
escapes from the body chiefly through the kidneys, the skin, the sali- 
vary glands, and it even appears in the milk of nursing women to such 
an extent that the nursing infant may be affected by iodism and suffer 
from gastro-intestinal disturbance in consequence of ingesting it. 

Poisoning.— The symptoms of acute poisoning by iodine are those 
of acute gastro-enteritis, such as severe pain in the esophagus, stomach 
and abdomen, accompanied by violent vomiting and purging. An 
early symptom is the persistent strong metallic taste in the mouth, 
with markedly increased salivation. The pulse becomes rapid, run- 
ning, and feeble, the face deathly pale, total arrest of urinary secretion 
takes place through renal irritation, and death occurs by failure of 
respiration, which is accompanied by loss of all vital power. 

If the poisoning is not severe enough to cause death at once, a fatal 
result is, nevertheless reached after a few days by reason of the severe 
gastro-enteritis and the widespread fatty degeneration of the tissues 
which iodine produces. 

The treatment of the poisoning consists in the use of large amounts of 
starch in any of its forms as the antidote, the employment of emetics 
and the stomach-pump, the application of heat to the body and 
extremities, and, finally, the employment of hypodermic injections of 
digitalis, and atropine or strychnine for the purpose of maintaining the 
strength of the circulatory and respiratory systems. 

Untoward Effects.— Under the name of "iodism" the profession 
recognizes a state of the body brought on by the prolonged and exces- 
sive use of iodine in any of its forms. The earliest notable signs of this 
state are a peculiar metallic taste in the mouth, particularly in the 
morning, slight tenderness of the teeth and gums, increase of salivary 
secretion, a little morning nausea, a lack of appetite for breakfast, 
and perhaps some coryza or evidence of gastric irritation. Acne 
rosacea often comes on very early during the use of full doses of iodine. 
If the drug is continued, all these symptoms become more marked 
and the coryza becomes intense. Frontal headache and sore-throat 
often appear, and the pustular and bleb-like changes in the skin go 
on to active suppuration. Sometimes large boils appear or purpura 



326 DRUGS 

hemorrhagica (iodic purpura) comes on. Slight catarrhal fever may 
develop. 

In other cases the nervous system chiefly suffers. Twitchings of 
muscles, neuralgic pains in the trunk and extremities, and wasting of 
the testicles, mammse, and all other tissues occur as the result of 
trophic disturbances. Anemia amounting to an actual cachexia is 
next produced. Loss of vision and paralysis may ensue in extreme 
cases. Soullier asserts that albuminuria may be developed in children 
after tincture of iodine has been freely applied to the skin, by reason 
of its absorption and irritation of the kidneys. 

Therapeutics.— In all cases where the glandular system is in a state 
of chronic perverted functional activity, as in those diseases associated 
with disorder of the processes of nutrition, and often included under 
the single name of scrofulosis, iodine is of service unless there is active 
tissue break-down. In enlargement of the lymph nodes it is one of the 
best remedies we possess, but it ought not to be employed in those 
cases where rapid changes are going on in the gland, such as the 
formation of pus, since under these circumstances it will increase the 
size of the slough. Neither will it benefit the glandular enlargement 
of Hodgkin's disease or lymphatic leukemia. The drug ought never 
to be used in acute pulmonary tuberculosis, because it tends to dis- 
integrate the tissues, and this is precisely what the disease is doing. 
In the exceedingly chronic form of pulmonary disease known as 
fibroid phthisis iodine may often be used with advantage. When 
inhaled as vapor it may be of service as a stimulant to the mucous 
membranes, but is never of value in phthisis so far as combating the 
true pathological change is concerned. In regions where goiter is 
very prevalent iodine ranks as a most efficient preventive of the 
development of the disease and should be taken by all young persons 
in moderate doses over long intervals of time. Its value after the gland 
is greatly enlarged is comparatively slight. (See Thyroid Gland.) 
In cases of exophthalmic goiter it is probably harmful in that the 
hypertrophied gland probably produces some of its symptoms by 
excreting too much iodine. Sometimes it is injected by means of a 
hypodermic needle into the gland. The usual dose is 10 to 15 minims 
(0.6-1.0) of the tincture every second or third day till twenty or 
more injections have been used. Meltzer states that while this treat- 
ment is sometimes efficacious, it is not devoid of danger, for at least 
thirty deaths have resulted from it. 

In chronic bone disease iodine applied about the affected joint in the 
form of the ointment diluted one-half with lard, or in the pure tincture 
will be found of service, and if anemia exists the syrup of the iodide 
of iron should be given internally. 

The other external uses of iodine are many and important. As a 
slow counterirritant, which does not produce pain if properly employed, 
it is particularly useful in children, and may be employed in one to 
three coats, and no more, applied by means of a camel's-hair brush. 



IODINE 327 

The proper way to use the tincture of iodine as a local counter- 
irritant for adults is to give one good black coat at one sitting and not 
to repeat it until the skin has desquamated and become well renewed. 
If iodine is applied after desquamation of the skin has begun, it will 
cause agonizing burning pain, which nothing will relieve except the 
removal of the iodine by the use of cologne- water, alcohol, whisky, or 
gin. The application of any of these liquids causes such an increase in 
the pain as to be almost useless after the skin is broken. The best 
solution for its removal is one of iodide of potassium, which should be 
followed by a starch poultice. A good rule to follow is never to cause 
pain by the use of iodine, as the drug acts equally well if applied in 
such a way as to avoid suffering. 

A stronger and more active preparation of iodine in solution for 
external use is that suggested by Elsberg. This preparation is of 
20 per cent, strength, whereas the ordinary tincture is 7 per cent. 
It is composed of iodine, 5 drams (20.0) ; alcohol and ether, of each, 
10 drams (40.0) . One or two coats of this solution painted upon the 
skin will produce as much effect as several of the ordinary tinctures, 
and as it dries rapidly it does not soil the clothing. 

In harassing, irritative cough tincture of iodine may be painted over 
the supraclavicular spaces, and it will sometimes lessen the secretion 
in chronic bronchitis if used in this way. In chronic rheumatism affect- 
ing the joints and muscles it does good when locally applied. Often in 
synovitis the local application of iodine, provided the skin is not 
inflamed, causes increased swelling for some days. This should not 
cause alarm, for ultimately the swelling decreases greatly, and the 
cases in which this occurs are generally the best from a prognostic 
point of view. 

In the course of phthisis every now and then a " spot" in the chest 
will become "sore," probably due to a limited area of pleurisy, and 
under these circumstances tincture of iodine locally applied will give 
relief. In lupus the tincture may be painted around the edges of the 
growth, and even over its surface, with the object of retarding its 
spread. In chilblains an application of iodine ointment gives the 
greatest relief if diluted one-half with lard, and its use is probably the 
most efficacious measure at our disposal. In certain individuals who 
have "pains in the chest" iodine ointment may do good if rubbed in 
over the affected spot. As has been pointed out by others, iodine does 
good if muscular tenderness is present, while it fails if pleurodynia or 
intercostal neuralgia is the cause of the suffering. The latter troubles 
should be removed by the use of belladonna. In certain forms of skin 
diseases, such as tinea tonsurans and circinata, tincture of iodine may 
be applied with a camel's-hair brush, and even the entire scalp may be 
painted. A better way is to apply it to different spots each day. 
When erysipelas is present, the tincture may be painted around the 
edges of the inflamed area in order to prevent its spread. 



328 DRUGS 

Tincture of iodine is a useful application to heal leg ulcers, painting 
it over and around the lesion. 

Within recent years tincture of iodine, in the form of the official 
tincture, or, more commonly, in 2 per cent, solution in ethyl alcohol, 
has been largely and successfully employed to sterilize the skin at the 
site of operative procedures. In scalp wounds, or wounds of other 
hairy parts, and in wounds filled with dirt, as in the case of crushed 
fingers or toes, the parts should be thoroughly painted and swabbed 
with tincture of iodine, and no other antisepsis is required. Washing 
the parts with water before using the iodine is unwise, as the water 
swells the cells and prevents the iodine from acting as a penetrating 
antiseptic. The surgeon can also sterilize his hands by dipping them 
in 2 per cent, iodine, and they may be largely decolorized afterward by 
washing them in a solution of boiled starch, hydrogen peroxide, or 
ammonia water, or a 3 per cent, carbolic acid solution. 

In old persons or those in middle life retraction of the gums from the 
teeth sometimes comes on with fetid breath. This can be greatly 
relieved or cured by rinsing the mouth twice daily with 5 drops (0.3) 
of tincture of iodine in 2 ounces (60.0) of water. 

In hydrocele iodine in the form of the tincture is one of the best drugs 
for effecting a permanent cure. The sac should first be emptied by 
the use of a trocar and cannula, and the tincture alone, or mixed with 
glycerin, injected with a syringe and then allowed to escape. As the 
pain produced by this injection is most atrocious, the patient should 
first be put under the influence of ether or some other anesthetic. 

Injections of iodine have been made into various serous cavities for 
the relief of chronic inflammatory processes. This is sometimes fol- 
lowed by unfavorable symptoms, and after the injection of tincture of 
iodine into the pleural cavity in hydrothorax symptoms of poisoning 
have come on in some cases, the most common complication being 
convulsions. These are epileptiform in character and are followed 
by coma or collapse. 

In empyema a solution of iodine 6 grains (0.4), iodide of potassium 
6 grains (0.4), and water 1 pint (480 cc) may be used daily as an 
irrigating fluid with good results; but this practice is not entirely 
devoid of danger, as too much of the iodine may be absorbed or the 
irritation produced in the chest by its injection may cause reflex and 
severe nervous symptoms. (For a better method see article on 
Antiseptics.) 

The tincture of iodine may be used, according to Ringer, as an 
inhalation with signal benefit in the following three instances : 

1 . In the chronic forms of phthisis (fibroid lung) . When the expec- 
toration is abundant and when the cough in troublesome, its inhala- 
tion, used both night and morning, will generally lessen expectoration 
and allay the cough. 

2. In children six to ten years of age, who after meals, or, inde- 
pendently of them, on exposure to cold, are seized with hoarseness, a 



IODINE 329 

hoarse, hollow cough and some wheezing in the chest. This affection, 
involving the larynx, trachea, and larger bronchial tubes, and often 
proving very obstinate, is apt to return and to persist for some time. 

3. Some persons suffer with itching of the nose, of the inner canthus 
of one or both eyes, sneezing, running at the nose, of a watery fluid, 
weeping of the eyes, and severe frontal headaches; and these patients of 
various ages are greatly troubled, often for many years, with daily 
attacks of this character, lasting, it may be, several hours. Iodine 
inhaled often relieves this affection at once, lessening the headache 
and discharge from the nostrils. Its effect is most marked in respect 
to the itching. 

Ringer generally adopts the following simple, handy, cleanly, and 
effectual plan of inhalation : Heat well a jug capable of holding about 
2 pints by rinsing with boiling water; then partly fill with boiling 
water, into which pour 20 to 30 minims (1.3-2.0) of the tincture 
of iodine; then direct the patient to put his face over the mouth of 
the jug and breathe the iodized steam, covering the head to prevent 
escape of the vapor. This inhalation should be used night and morn- 
ing for five minutes or a little longer. Occasionally an excess of iodine 
will temporarily produce a sensation of soreness in the chest and 
throat, accompanied with redness of the conjunctiva, running from 
the nose, and pain in the head. 

In some cases of acute coryza much relief may be obtained by sniffing 
the fumes of tincture of iodine from a bottle, as in the use of " smelling 
salts." The heat of the hand is sufficient to disengage the vapor in 
proper quantity. 

A useful gargle in cases of relaxed sore-throat is a follows : 

3— Tincturse iodi f3j (4.0) 

Potassii iodidi . 3j (4.0) 

Spiritus vini gallici f 5j (30.0) 

Aquae destillatae q. s. ad fSiv (120.0). — M. 

S. — Use 2 teaspoonfuls (8.0) in half a glass of water as a gargle three times a day. 

An alcoholic solution of iodine of the strength of one-half of 1 per 
cent, is an efficient disinfectant for the hands. The color can be 
removed by rinsing with dilute ammonia water. 

Administration.— Iodine is never used in solid form, and it has 
been taught that the tincture {Tinctura Iodi, U. S., and Tinctura Iodi 
Mitis, B. P.) should not be given internally, on the ground that it is 
precipitated in the stomach. Whether this be true or false, it is a 
fact that the tincture has been largely used in the vomiting of preg- 
nancy and that occurring after the use of anesthetics with very good 
results. The dose is 5 to 10 minims (0.3-0.6), 2 to 5 minims (0.12- 
0.3), B. P., well diluted. Under the name of Lugol's solution {Liquor 
Iodi Compositus, IT. S.) iodine is frequently used internally as an 
alternative and substitute for iodide of potassium; the dose is 5 to 10 
minims (0.3-0.6), in water. Tinctura Iodi Fortis, B. P., is used as a 
local application. 



330 DRUGS 

Unguentum Iodi, U. S., and B. P., is used locally over enlarged 
glands. In the case of children or adults who have delicate skins the 
ointment should be diluted one-half with lard. This ointment should 
always be freshly made. 

Contraindications.— Iodine when given internally is contraindicated 
in renal diseases, except in small doses, during the progress of acute 
inflammation, and whenever tissues are rapidly undergoing a break- 
ing-down process. 

IODOFORM. 

Iodoform (Iodoformum, U. S. and B. P.) occurs in a fine lemon- 
yellow powder or lustrous crystals of the hexagonal system, having a 
peculiar, very penetrating, and persistent odor, and an unpleasant, 
slightly sweetish, and iodine-like taste. It is soluble in 9391 parts of 
water, to which it imparts its odor and taste, in 60 parts of alcohol 
and in 7.5 parts of ether at 25° C. (77° F.) ; in about 16 parts of boiling 
alcohol ; in chloroform and fixed and volatile oils ; and is slightly solu- 
ble in petroleum benzin. 

Physiological Action.— The effects of iodoform upon the circulation, 
respiration, and other vital functions are very slight when the drug is 
used as a surgical dressing in ordinary amounts or when it is given by 
the mouth in average doses. It acts as an anesthetic upon mucous 
membranes, and produces those changes which we are wont, for want 
of a better term, to call "alterative," in the tissues with which it 
comes in contact. Iodoform is eliminated in the urine as iodine or as 
alkaline iodides, chiefly as iodide of sodium. The drug also escapes 
by the saliva as an alkaline iodide. 

Poisoning.— If applied to an absorbing surface in susceptible indi- 
viduals, iodoform may cause general systemic poisoning. This poison- 
ing may be mild, in which case there is a general feeling of malaise, 
with nausea and the perception of various odors which are in reality 
not present. There may be headache and vomiting. If the system 
is still more impressed by the drug, these symptoms are followed by 
cerebral excitement, insomnia, loss of memory, loss of appetite, and a 
rapid pulse. In grave cases convulsive movements and maniacal 
delirium, alternating with coma, may be the dominant symptoms. 
The pulse is small and rapid, and there is often retention of urine or 
hematuria. Loebisch asserts that the mental excitement cannot be 
quieted by narcotics. If death occurs, the heart and respiration fail 
simultaneously. In addition to the fatty degeneration which such 
poisoning produces in all the vital organs, there is sometimes found an 
edematous condition of the pia mater or a low-grade leptomeningitis. 
These symptoms seem to occur more commonly in the aged. In the 
graver cases the onset of the poisoning is apt to be sudden, though 
from twenty-four hours to several days usually elapse between the 
application of the drug and the onset of the symptoms of poisoning. 



IODOFORM 331 

Treatment of the poisoning by iodoform consists, according to 
Soullier, in the administration of bicarbonate of sodium to unite with 
the iodine and so aid in its elimination; the use of alcoholic stimulants 
to support the system; the employment of diuretics, and wrapping the 
patient in hot blankets to encourage free sweating, so relieving the 
kidneys. Kocher advised saline transfusion in such cases. 

Untoward Effects.— It is not to be forgotten that iodoform when 
applied as a dressing may produce less violent symptoms than those 
just described. Sometimes a scarlatinal rash may develop with fever, 
malaise, and nervous disturbances. 

Therapeutics.— Iodoform is used chiefly as a surgical dressing, but 
is by no means so popular for this purpose as it was at one time. It is 
antiseptic, but not germicidal. Germs may be found in powdered 
iodoform, and will even grown in it. When used locally, the drug does 
good by absorbing the liquids of the wound, and thereby removing the 
nidus for germ-growth, and when applied to large moist surfaces gives 
off free iodine and acts as well as a protective. There can be no doubt 
that iodoform when applied to a wound does good, not by destroying 
the bacteria directly or indirectly, but by inducing chemical changes 
in their toxins. 

In syphilitic sores the following dressing will be found of great 
service: Iodoform, 20 grains (1.3); oil of eucalyptus, \ fluidounce 
(16.0); or a powder of iodoform \ ounce (16.0), camphor 75 grains 
(5.0), and essence of rose 2 drops (0.1), may be employed. In eczema, 
with tingling and itching, the following application will give relief 
(Ringer) : 

R; — Iodoformi gr. iv (0.25) 

Olei eucalypti f3j (4.0) 

Petrolati 5j (30.0).— M. 

S. — Apply locally. 

Internally, iodoform is used in tertiary syphilis in all its forms in 
the dose of from 1 to 5 grains (0.6-0.3). Bartholow recommended 
it most highly in catarrhal jaundice and in the early stages of hepatic 
cirrhosis. 

The influence of iodoform upon the tubercle bacillus is very great, 
and it is largely used in the treatment of tubercular disease of the 
joints and pleurce. The pus is allowed to escape under antiseptic pre- 
cautions; the cavity is washed out with warm boric acid or phenol 
solutions of low strength, and from 1 to 6 drams (4.0-24.0) of an 
emulsion of iodoform and sterilized sweet oil are injected and allowed 
to remain. The strength of the iodoform-and-oil emulsion should 
usually be 10 per cent. Should the abscess cavity fail to heal after 
these injections have been repeated every few days for. some time, it 
must be reopened, scraped, and injected again or packed with iodo- 
form gauze. The iodoform also promotes healing through its altera- 
tive influence, which aids in the absorption of the inflammatory 



332 DRUGS 

exudate. Should tubercular glands be present, injections may be 
made into them even if pus has not formed. 

Used by means of a powder-blower, iodoform will often relieve the 
hoarseness and discomfort of laryngeal phthisis, but it must be pulver- 
ized most minutely. Sometimes a spray may be used, which should 
consist of spirit of turpentine and sweet oil, half-and-half, and con- 
tain 2 grains (0.12) of iodoform to each ounce (30.0). This mixture 
may also be used in chronic bronchial catarrh to lessen the cough and 
fetid discharge. In the early stages of phthisis several clinicians 
claim to have obtained good results by the daily hypodermic injection 
into the back of 30 minims (2.0) of a 1 : 100 solution of iodoform in oil 
of sweet almonds, but this treatment has not found favor, in the 
United States at least. 

For fissure of the anus and irritated hemorrhoids 5 grains (0.3) of 
iodoform in a suppository may be placed in the rectum, and after it 
has remained there a few minutes defecation may take place with 
little or no pain. The pain following operations on the female peri- 
neum may also be much relieved in this manner. In the rectal 
tenesmus of cholera infantum an injection of 1 ounce (30.0) of sweet oil 
with 5 grains (0.3) of iodoform will give great relief if used after or 
before enteroclysis. 

Administration.— The ointment of iodoform ( Unguentum Iodoformi, 
U. S. and B. P.) is useful when applied over fetid sores. It should 
always be freshly made. The drug itself may be given in 1- to 5-grain 
(0.06-0.3) doses three times a day. The suppositories (Suppositoria 
Iodoformi) are official in the B. P.; each one contains 3 grains (0.2) 
of iodoform. (See also Europhen and Thymol Iodide.) 

IODOL. 

Iodol is a light grayish-brown, crystalline powder, without odor 
or taste. It is soluble in about 4900 parts of water, 9 parts of alcohol, 
1.5 parts of ether, 105 parts of chloroform at 25° C. (77° F.), and 
in fixed oils. It is also soluble in concentrated sulphuric acid, pro- 
ducing a green solution gradually changing to brown. It should be 
kept in amber-colored bottles. Its uses in medicine are identical 
with those of iodoform, and it possesses the advantage of having a 
less penetrating odor than the latter drug. 

In tubercular laryngitis the very finely powdered drug may be blown 
into the larynx without disagreeable results and with a favorable 
effect on the disease process. Cerna has found iodol of great service in 
diabetes when given internally in the dose of from 2 to 6 grains (0.12- 
0.4) three times a day, and it is said to be of value in tertiary syphilis 
in the same quantity. 

A useful antiseptic dressing for small wounds and abrasions is 
made by adding 1 part of iodol to 10 parts of ether and 5 of gun-cotton, 
thereby preparing an iodol collodion. 



IPECACUANHA 



333 



Ingalls recommends the following prescription in cases of eczema or 
abrasions of the upper lip and nostrils : 

3— Phenolis 1Uv (0.3) 

Olei rosge TTlv (0.3) 

Iodoli gr- xxv (1.6) 

Adipislanse 5ss (16.0).— M. 



IPECACUANHA. 

Ipecacuanha, U. S., or Ipecacuanha Radix, B. P., or ipecac, is the 
root of Ceph&lis ipecacuanha (Psychotria ipecacuanha, B. P.), a 
small shrub of Brazil yielding, when assayed by the U. S. P. process, 
not less than 1.75 per cent, of ipecac alkaloids; by the B. P. process, 
2 per cent. It contains the 
alkaloids, emetine {Emetinas 
hydro-chloridum, U. S.), cephse- 
line and psychotrine. Only 
emetine is used in medicine. 

Physiological Action. —Local- 
ly applied to mucous mem- 
branes, ipecac acts as an 
irritant, and if applied for a 
long period to the skin produces 
vesicles and irritation. Very 
minute doses have little notice- 
able effect, but large ones 
produce nausea, relaxation, 
vomiting, free secretion into the 
bronchial tubes, and a profuse 
flow of saliva. The emesis has 
been thought to .be due both to 
the irritation of the stomach 
and to an effect upon the vomit- 
ing center in the medulla (Fig. 51), but the large doses of emetine 
now used by the hypodermic needle in the treatment of amebic 
dysentery without producing vomiting w r ould seem to prove that 
ipecac given by the stomach acts on that organ directly. Ipecac is 
eliminated by the kidneys, the gastro-intestinal mucous membrane, 
and the skin (Binz). 

If emetine is given in lethal dose to one of the lower animals, death 
is due to failure of respiration, but when it is given by a vein it acts 
as a powerful cardiac depressant as well. For this reason, if emetine 
is given intravenously, it should be put in 100 cc of normal salt 
solution and injected slowly. 

Therapeutics.— Ipecac is used as an emetic where a fairly rapid 
action is required. It is particularly useful where the stomach of a 
child is overloaded with food. In cases of poisoning it is hardly 
active or rapid enough as an emetic, and is not so good as mustard or 




Fig. 51. — A, vomiting center in the medulla 
said to be stimulated by ipecac; B, nerves in 
mucous membrane of stomach irritated by 
ipecac. 



334 DRUGS 

sulphate of zinc. In babies and young children an attack of bronchitis 
often causes digestive disorders by reason of the mucus coughed up 
from the lungs being at once swallowed instead of spat out of the 
mouth. In these cases the stomach may be relieved and the state of 
the lungs improved by the use of an emetic dose of syrup of ipecac, 
2 to 3 drams (8.0-12.0). Often if this dose be not large enough to 
produce emesis it will purge the child and remove the mucus by the 
bowel. 

In some cases of obstinate vomiting small doses of ipecac will act as 
a most successful cure, provided that the vomiting is due not to inflam- 
mation and excitement, but to depression. The proper dose of ipecac 
for this purpose is § to J grain (0.008-0.015) or less every half-hour 
until five or six doses are taken. 

In some cases of the vomiting of pregnancy it is useful, in toxic cases 
it utterly fails; 1 minim (0.06) of the wine or | to J grains (0.008-0.015) 
of the powdered ipecac, repeated every half-hour for six or seven doses, 
is all that should be used. In the morning vomiting of drunkards 
ipecac is of service, but it is not as good a remedy as are small amounts 
of arsenic or hydrochloric acid. 

In true amebic dysentery ipecac, or its alkaloid emetine, is the best 
remedy we possess. When the disease is malignant, as it occurs in 
the tropics, ipecac should be given in the following manner: The 
ipecac is to be given on an empty stomach in the dose of 30 grains 
(2.0) in freshly made pills of 5 grains (0.35), coated with salol or 
keratin, so that the ipecac will not irritate the stomach, but be dis- 
solved in the bowel. When this causes vomiting it may be preceded 
one hour by 30 minims (2.0) of tincture of deodorized opium, or 20 
grains of chloral, which is used to decrease the tendency to vomit. 
This dose should be repeated every night for three or four nights, and, 
in severe cases, for a week or more. Absolute rest in bed for two 
weeks is essential for success. Finally, a profuse gray, mushy stool is 
passed. The passage of this stool is a most favorable prognostic sign, 
and its non-appearance is equally significant of failure. There now 
occurs a decrease in pain and a lessening of the fever and of bloody 
discharges. Retching, vomiting, delirium, and exhaustion do not 
contraindicate this plan of treatment. If the first dose is rejected, it 
may be repeated in a few hours, preceding it by the laudanum. 
Counter irritation is to be applied to the belly, and stimulants freely 
used to combat great depression. It is asserted by Rogers and many 
others that, if this plan of treatment is used in the early stages of 
amebic dysentery and hepatitis, hepatic abscess can be prevented in 90 
per cent, of the cases. Rogers gives 30 grains (2.0) daily for a period 
of two or three weeks in such cases. If an abscess has formed, it 
must be evacuated by puncture, injected with quinine solution, and 
the ipecac continued. 

Vedder, of the U. S. Army, has proved that the emetine in ipecac 
is destructive to the ameba dysenteric, and more recently Rogers has 



IPECACUANHA 335 

shown that the dose of ipecacuanha named above can be efficiently 
substituted by the intramuscular injection once or twice a day of 
| to f grain (0.03-0.04) of emetine hydrochloride dissolved in 30 
minims (2.0) of normal salt solution. By this means nausea and 
vomiting are avoided and a cure is effected in about half the time. 
Such doses can now be obtained already prepared in sterile ampoules, 
or if need be the solution can be boiled before it is used. In obstinate 
cases both emetine intramuscularly and ipecac by the mouth are to 
be resorted to, cleansing the bowel first with a saline purge. Exces- 
sive diarrhea is to be controlled by paregoric. A cure is not produced 
until the stools fail to show the Entamebce histolytica. Usually a 
course of at least fifteen days is required, but after the first seven 
days, an interval of seven days' rest should be allowed. In severe 
cases the emetine hydrochloride should be diluted with normal salt 
solution and given very slowly intravenously, particularly in the 
stage of onset. It is becoming increasingly evident, however, that 
although emetine given hypodermically destroys the active amebae, 
it does not affect the encysted forms and that the patient is not really 
cured but the active condition merely palliated, for relapses are com- 
mon after some time and the patient endangers others by being a 
carrier. When the patient is very ill the emetine may be used first 
and when improvement occurs the full effect of the crude powdered 
drug may be obtained by its use. 

In choleraic diarrheas and cholera morbus ipecac is said to be of 
service in the dose of 3 grains (0.2) every two hours if opium is given 
to control nausea. 

Xo less a person than Trousseau asserted that ipecac was a hemo- 
static, and it is said to be a most effective remedy in small doses in 
hemoptysis, and in all hemorrhages which are capillary in character, 
but the manner of its action is obscure. 

Ipecac may be used in the early stages of bronchitis, to act as a seda- 
tive to the inflamed mucous membrane and to promote secretion. 
Under these circumstances it is best combined with citrate of potas- 
sium. (See Bronchitis.) 

Ringer and Murrell have found that inhaling ipecac spray is very 
useful in chronic ivinter cough or bronchitis, particularly when there is 
present shortness of breath. The pure wine may be used in a spray 
apparatus or be diluted one-half with water. While the throat may 
seem temporarily worse, the shortness of breath rapidly decreases and 
marked improvement takes place in the cough. In order to prevent 
the wine which collects in the mouth from being swallowed, and 
nausea and vomiting thereby induced, the patient should be directed 
to rinse his mouth thoroughly every few minutes. The inhalation 
should not last at first over three or four minutes, and, until it is known 
how well the patient will bear the application, the wine should be 
diluted twice or thrice with water and alcohol, equal parts. 



336 DRUGS 

It is stated that powdered ipecac smeared on the skin will greatly 
relieve the pain and swelling produced by the stings of bees. 

Untoward Effects.— The hypodermic use of emetine is prone to 
produce local inflammation and pain. The free use of emetine in 
pregnant or menstruating women is contraindicated owing to its 
stimulating effects on the uterus. In pregnancy not more than J 
grain a day is to be given, as it may cause abortion in larger doses. 
When given in full repeated doses by the mouth, diarrhea and neuritis 
may develop. This is also true of too generous hypodermic or intra- 
muscular medication, and death from general asthenia and cardiac 
failure may follow its too free use. It seems to have a cumulative 
effect in certain instances. 

Administration.— The syrup (Syrupus Ipecacuanha?, U. S.) is given 
in the dose of J to 1 dram (2.0-4.0) as an expectorant, or in the same 
dose as an emetic to an infant. Fluidextractum Ipecacuanhce (U. S.), 
Extractum Ipecacuanha? Liquidum (B. P.) should contain 1.5 gram, of 
alkaloids in each 100 cc and is given in the dose of 30 minims (2.0) 
as an emetic to an adult. The troches ( Trochisci Ipecacuanha?, B. P.) 
contain J grain (0.015) each. Trochisci Morphina? et Ipecacuanha 3 , 
B. P., each of which contains -^ grain (0.002) of morphine and T V 
grain (0.005) of ipecac, are used in sore-throat, dissolved in the mouth. 
Dover's powder (Pulvis Ipecacuanha? et Opii, U. S.; Pulvis Ipecac- 
uanha? Composite, B. P.) is given in the dose of 5 to 20 grains (0.3- 
1.3). It contains 1 part of opium, 1 part of ipecac, and 8 parts of 
sugar of milk. (See Opium.) The dose of emetine {Emetina? hydro- 
chloridum, U. S.), by the needle is J to f grain (0.025-0.04). 

The additional British preparations are the pill of ipecac and squill 
(Pilula Ipecacuanha? cum Scilla, B. P.), given in the dose of 5 to 10 
grains (0.3-0.6), and the vinegar of ipecac (Acetum Ipecacuanha?, 
B. P.), given in the dose of 5 to 30 minims (0.3-2.0), which are used 
as expectorants. 

IRON. 

Iron (Ferrum, U. S. and B. P.) is a metal which is used both as a 
medicine and a food— a food because it forms part of the body when 
taken into the organism and is used by the system in the making of 
blood. The number of its official salts and compounds is far in excess 
of the needs of practical physicians, and half the preparations are 
rarely, if ever, used. 

Physiological Action.— Iron has little or no effect upon the system 
when given in a single dose, but repeated doses cause an increase in 
the number of red blood-corpuscles, and plethora, or an increase in the 
quantity and quality of the blood. Much discussion has arisen as 
to whether iron is absorbed when given as a drug in the form of one of 
the inorganic salts. One theory has been that only the organic iron 
of the food is absorbed, and that metallic iron when given freely 
allows this absorption to go on both by stimulating the bowel and by 



IRON 337 

entering into combination with the sulphuretted hydrogen in the 
intestine, thus permitting the organic iron to escape into the system. 
That both forms of iron are absorbed and eliminated is now certain. 
(For a discussion of some of these views, see article on Anemia.) The 
absorption of iron takes place chiefly in the first twenty inches of the 
small bowel and takes place through the epithelial cells. The iron 
granules are then taken up by the leukocytes and carried to the liver, 
although some of them may be deposited in the mesenteric glands. 
Some of it also is deposited in the bone-marrow. Iron, when^it 
enters the stomach, is probably changed into the chloride, and then, on 
entering the duodenum, is changed to the carbonate. If, however, 
iron is given in excessive doses, much of it remains unabsorbed; it is 
changed into the sulphide of iron in the bowels and escapes with the 
feces. Careful studies have shown that the iron, when once absorbed, 
escapes from the body very slowly, and that its pathway of escape is 
not by the bile or in the urine, but by the walls of the colon and rectum, 
which excrete it, so that it may be recovered from the feces. It has 
been asserted that it is never released from the body, but this is untrue. 
Whether it acts as a stimulant to blood-manufacture or simply sup- 
plies the glands with blood-making material is not known, but the 
latter is probably the correct view. Iron, perhaps, causes oxidation 
to go on more rapidly by reason of its peculiar power of converting 
oxygen into ozone, and in this manner acts as a stimulant to nutrition 
and bodily activity. 

The preparations of iron consist in the soluble and insoluble salts or 
forms. Of these the insoluble are better than the soluble, because 
nearly all the soluble salts of iron are precipitated by the gastric juice 
and have to be slowly redissolved. Nearly all iron preparations are 
capable of acting as more or less powerful astringents, and so are apt 
to cause constipation and to disorder digestion if given in large doses. 
The most astringent of all these preparations are Monsel's salt (the 
Ferri Subsulphas, U. S. and B. P.) and ferrous sulphate (Ferri Sul- 
phas, U. S. and B. P.). Closely following these in astringency are the 
ammonio-f erric alum (Ferri et Ammonii Sulphas) , and ferric chloride 
(Ferri Chloridum, U. S.). The least astringent preparations are 
Quevenne's iron, or iron by hydrogen (Ferrum Reductum, U. S. and 
B. P.), saccharated ferrous carbonate (Ferri Carbonas Saccharatus, 
U. S. and B. P.), Basham's mixture (Liquor Ferri et Ammonii Acetatis, 
U. S.), the citrates, tartrates, and the lactate and phosphate of iron. 

Therapeutics.— The chief indications for the administration of iron 
are those forms of anemia (see Anemia) characterized by a decrease 
in the normal quantity of hemoglobin in the blood as determined by 
the hemoglobinometer, as, for example, chlorosis. Its chief contra- 
indication is plethora. When used in small dose (} to \ grain— 0.015- 
0.3) it is quite as efficacious as in large amounts, and less apt to dis- 
order the stomach, but the doses given in this article are the classical 
ones usually prescribed by physicians. In some cases of anemia of a 
22 



338 DRUGS 

semi-pernicious type large doses of iron are really needed, probably 
because the system is deranged in such a manner that an excessive 
loss or elimination of iron is constantly present. Large doses com- 
pensate for this leakage and afford the quantity needed for physio- 
logical purposes. Iron should not be used as a tonic unless some direct 
indication for its employment is present, and no drug is more abused, 
in this respect than iron. As every preparation possesses some 
peculiarity, the use of each will be considered separately. 

Ammonio-ferric Alum. 

Ammonio-ferric alum (Ferri et Ammonii Sulphas), is often given 
in cases of atonic leucorrhea associated with chlorotic tendencies in the 
dose of 2 to 5 grains (0.12-0.30). Why it is thought more advan- 
tagous than other preparations is difficult to discover. It is quite 
astringent, and should not be given in cases of gastric irritability, 
as it is not suited to such a condition. 

Aromatic Mixture of Iron. 

The aromatic mixture of iron (Mistura Ferri Aromatica) contains 
so little iron that it should not be administered in cases where a very 
marked chalybeate influence is desired; it is, however, a useful tonic 
for cases of debility and slight anemia following long illness, given 
in the dose of 1 to 2 fluidounces (30.0-60.0) after meals. Aromatic 
mixture of iron contains cinchona bark, calumba, cloves, iron, com- 
pound tincture of cardamoms, tincture of orange peel, and pepper- 
mint water. 

Arsenate of Iron. 

Ferrous arsenate (Ferri Ar sends) is used in the dose of yg- to T V 
grain (0.004-0.005) in anemic subjects who are suffering from the 
dry, scaly forms of skin disease which indicate the use of arsenic. 
(See Arsenic.) 

Ba sham's Mixture. 

Under the name of Basham's Mixture (Liquor Ferri et Ammonii 
Acetatis, U. S.) a very useful and elegant preparation of iron is 
employed. It is chiefly employed in the anemia of acute and chronic 
parenchymatous nephritis, as it also acts as an efficient diuretic and 
mild diaphoretic. (See Nephritis.) It is made up as follows : 

Tincture of chloride of iron 4 parts. 

Dilute acetic acid 6 " 

Solution of ammonium acetate 50 " 

Aromatic elixir . . 12 " 

Glycerin 12 " 

Water 16 " 

The dose is from 1 to 4 drams (4.0-16.0), well diluted. 



IRON 339 

Cacodylate of Iron. 

Under the name of cacodylate of iron a compound has been intro- 
duced which is given in cases of anemia, in which the hemoglobin and 
the corpuscles are lacking, since by this means we obtain the effect of 
both iron and arsenic. The salt may be given by the mouth in the 
dose of | to 1 grain (0.015-0.06) three times a day, in solution, or in 
urgent cases in the dose of | to J grain (0.008-0.015) by the hypo- 
dermic needle three times a day. It is asserted by Gilbert and 
Tereboullet that this is not productive of local or renal irritation, and 
in the albuminuria of 'tuberculosis may even be beneficial. 

Carbonate of Iron. 

The saccharated ferrous carbonate (Ferri Carbonas Saccharatus, 
U. S. and B. P.) is very slightly astringent, and may be used in pill 
form under the name of Pilule Ferri Carbonatis, U. S. (Pilula Ferri, 
B. P.), sometimes called "Blaud's pill," or in Griffith's pill, which also 
contains myrrh. The dose is about 3 grains (0.2), 5 to 15 grains 
(0.3-1.0), B. P. This preparation of iron is largely used for the treat- 
ment of amenorrhea dependent upon anemia. Under the name of 
Mistura Ferri Composita, B. P., or Griffith's mixture, a liquid pre- 
paration is used for the same purposes as the pills just named, in the 
dose of 1 to 2 tablespoonfuls (15.0-30.0). Massa Ferri Carbonatis, 
U. S., sometimes called Vallet's mass, is given in pill in the dose of 
from 1 to 10 grains (0.06-0.6). 

Chloride of Iron. 

Tincture of ferric chloride (Tinctura Ferri Chloridi, U. S.; Tinctura 
Ferri Perchloridi, B. P.), often called tincture of the muriate of iron, 
is one of the best and most useful preparations of iron. It is a mild 
diuretic. This diuretic effect does not depend upon the presence of 
muriatic ether, as has been taught, since this is not present, and is 
difficult to prepare except there is an excess of chlorine. According 
to researches of Dr. S. ^Yeir Mitchell, the only ether present it 
nitrous ether, and this is devoid of power used in small quantity. 
As chloride of iron itself is diuretic, it is probable upon this that 
the diuresis produced by it depends. The dose of the ferric chloride 
(Ferri Chloridum, U. S.) is 1 to 3 grains (0.06-0.2). Tincture of 
ferric chloride is considered a specific in erysipelas, and should be 
given in full dose and frequently repeated if it is to be of any service. 
(See Erysipelas.) Ten minims (0.6), well diluted, every hour are not 
too much if the stomach of the patient does not rebel. In chronic 
Bright 's disease it is of value in that it sometimes decreases the 
albuminuria, but it possesses no curative power for obvious reasons. 
In secondary anemia it is useful, and owing to its acid content is a 



340 DRUGS 

doubly effective tonic in cases in which not only iron but hydrochloric 
acid is needed. The dose of Liquor Ferri Chloridi, U. S., is 4 to 10 
minims (0.25-0.6). It is rarely used internally, but chiefly as a 
powerful local astringent. Liquor Ferri Chloridi, is identical with 
Liquor Ferri Perchloridi, B. P. Tinctura Ferri Perchloridi, B. P., is 
used internally in the dose of 5 to 15 minims (0.3-1.0). 

Given by the stomach, tincture of ferric chloride is useful in tonsil- 
litis. It is best to give it in large doses, with an ice-bag placed on the 
anterior part of the neck. When used internally it should be well 
diluted with water and taken through a glass tube to protect the teeth. 
The strong solution of perchloride of iron (Liquor Ferri Perchloridi 
Fortis, B. P.) is a powerful styptic. 

Citrates of Iron. 

The four citrates of iron are soluble in water and so are readily 
added to liquid prescriptions, and they are also of value because they 
are but slightly irritant and astringent and do not disorder the alimen- 
tary canal. Ferri Citras, and Ferri et Ammonii Citras, U. S. and B. P., 
occur in garnet-red scales, and are given in the dose of 5 grains (0.3) . 
The solution of the citrate of iron (Liquor Ferri Citratis) is given in 
the dose of 10 minims (0.6). Ammonio-citrate of iron in solution 
in sterile glass ampoules is now placed upon the market for intra- 
muscular use, usually with a small amount of quinine and urea hydro- 
chloride to prevent pain. (See Anemia.) The Ferri et Quinince 
Citras, B. P., and the Ferri et Strychnines Citras are given in the dose 
of 3 to 5 grains (0.15-0.3) and 1 to 3 grains (0.06-0.2), respectively. 
Ferri et Quinina Citras Solubilis, U. S., is given in the dose of 3 to 5 
grains (0.15-0.3). 

Hydroxide of Iron. 

Ferric hydroxide (Ferri Hydroxidum) is the antidote to arsenic, but 
to be efficacious it must be freshly prepared. It is to be made by 
precipitating any liquid preparation of iron by the addition of an 
alkali, such as ammonia, or by the addition of magnesium oxide. 
The resulting precipitate is the antidote, and the supernatant liquid is 
to be poured off. If ammonia is used, the precipitate must be washed 
with water several times to get rid of the alkali, which will render the 
antidote too irritant to be swallowed if it is allowed to remain with the 
precipitate. Magnesia is an antidote in itself, and should be preferred 
under all circumstances. The antidote should be given in excess, and 
as much as a pint of the iron solution should be precipitated. The 
magnesium oxide should be freely added, as too much of it cannot be 
given. The antidote to arsenic is official as Ferri Hydroxidum cum 
Magnesii Oxido, U. S. In the Prussian Pharmacopoeia this is known 
as the Antidotum Arsenici. (See Arsenic, Poisoning by, for official 
method of preparing antidote.) 



IRON 341 



Iodide of Iron. 



The syrup of ferrous iodide (Syrupus Ferri Iodidi, U. S. and B. P.) 
is a syrupy liquid of a sweet, iron-like taste, containing about 5 per 
cent, by weight of ferrous iodide. It should contain no free iodine, 
and if a sample of it strikes a blue color with starch it should be 
discarded. It is largely used in anemia associated with catarrhal 
states, and is useful in the eczema of young children when this is de- 
pendent upon lack of vitality or anemia. The dose to a child of 
two years is 3 to 6 minims (0.2-0.4), well diluted, and to an adult 30 
to 40 minims (2.0-2.6) in water, to be taken through a glass tube to 
protect the teeth. 

The saccharated ferrous iodide (Ferri Iodidum Saccharatum) is 
used in place of the syrup in the dose of 2 to 5 grains (0.12-0.3). The 
official pills of ferrous iodide (Pilules Ferri Iodidi, U. S.) each contain 
1 grain (0.06) of ferrous iodide, and are given in the dose of one to 
three pills. 

Lactate of Iron. 

Ferrous lactate (Ferri Lactas) is soluble in 48 parts of water, and 
is given in the dose of 5 grains (0.3). It is used for the same purposes 
as the other preparations of iron. Ferrous lactate is one of the ingre- 
dients of the formerly official Syrupus Hypophosphitum cum Ferro, 
the dose of which is § to 1 fluidram (2.0-4.0). 

Phosphates of Iron. 

There are two phosphates of iron — Ferri Phosphas Solubilis, U. S., 
or Ferri Phosphas Saccharatus, B. P., and Ferri Pyrophosphas Solu- 
bilis. Ferric phosphate itself is insoluble and is rarely used. The 
official forms are, however, quite soluble, and useful in the dose of 2 
to 5 grains (0.12-0.3). Syrupus Ferri Phosphatis, B. P., is given in 
the dose of 1 fluidram (4.0) . Phosphate of iron is one of the ingre- 
dients of Syrupus Ferri Phosphatis cum Quinina et Strychnina, B. P., 
which is given in the dose of 1 fluidram (4.0), and of the elixir of 
iron, quinine, and strychnine phosphates (Elixir Ferri, Quininw et 
Strychnince Phosphatum), given in the same dose as the syrup. 

Reduced Iron. 

Quevenne's iron (Ferrum Reductum, U. S., Ferri Redactum, B. P.) 
is an iron-gray or reddish powder which is frequently adulterated 
with lampblack. If it is pure, it should burn in sparks when dropped 
into a flame; but if lampblack is present this will not occur. It should 
also yield no sulphuretted hydrogen on adding sulphuric acid to it. 
It is tasteless, and may be given to children for this reason in pills or 



342 DRUGS 

gum-drops, or placed inside of small chocolate creams, or in the form 
of troches (Trochisci Ferri Redacti, B. P.), each lozenge containing 
1 grain (0.06) of the reduced iron. It is used solely in anemia, and is 
one of the least astringent of the iron preparations. Dose ^ to 2 
grains (0.006-0.12). 

Subsulphate of Iron, or Monsel's Salt. 

Monsel's solution (Liquor Ferri Subsulphatis, U. S.; Liquor Ferri 
Persulphatis, B. P.) is sometimes wrongly called the solution of the 
persulphate of iron, and is one of the most powerful styptics or 
hemostatics that we have. It is never to be employed where a hemor- 
rhage is to be controlled through the circulation, but only when the 
solution can come in direct contact with the bleeding spot. The 
objection to its use is the hard, black, and dirty clot which it forms on 
coming in contact with blood. In hemoptysis Monsel's solution 
has been used in fine spray consisting of from 10 to 60 minims (0.6- 
4.0) to the ounce (30.0) of distilled water. It is useless because it 
does not reach the bleeding spot. In uterine hemorrhage from any 
cause the dilution may be half-and-half, or if the hemorrhage be from 
a polypus or the cervix uteri the pure solution should be used, locally 
applied. In nose-bleed Monsel's solution may be employed diluted 
one-half or pure; but its use is not to be commended, because of the 
hard, black clot which is formed and the uncomfortable sensations 
and pain produced in the nasal chambers. Plugging the nostrils, 
and if need be the posterior nares, with pledgets of cotton is generally 
sufficiently efficacious particularly if the cotton is wet with adrenalin 
solution. 

For the intestinal hemorrhage occurring during or after typhoid fever 
Monsel's solution has been given, but should not be so employed, as 
it is decomposed in the stomach before it reaches the intestine. In its 
stead MonseFs salt (Ferri Subsulphas) may be given in pills of 3 
grains (0.2) each, the pills being made hard enough to escape into the 
intestine before the stomach dissolves them. One pill may be given 
every hour but it is an uncertain remedy. Hematemesis due to bleed- 
ing in the stomach may be treated by 3-minim (0.2) doses of the solu- 
tion in a little water. It should be remembered, however, that the 
drug is irritating if frequently repeated. 

In tonsillitis and pharyngitis a quite efficient application is pure 
Monsel's solution applied by means of pledget of cotton or camel 's- 
hair brush, or equal parts of the solution and glycerin may be used. 
This application is often as painful as it is efficient, and care must be 
exercised that an excess of the fluid be not present, as it may drop 
into and irritate the larynx. In diphtheria this method of treatment 
may be used if peroxide of hydrogen cannot be obtained. 

The antidote to Monsel's solution is common soap. 



IRON 343 



Sulphate of Iron. 

Ferrous sulphate (Ferri Sulphas, U. S. and B. P.) is used internally 
in the dose of 5 grains (0.3) in pill form in chronic diarrhea with 
anemia. Externally, in a solution of the strength of 5 to 25 grains to 
the ounce (0.3-1.6 : 30.0), it is used as an astringent lotion. Two 
other forms of the sulphate are also employed— namely, the dried 
(Ferri Sulphas Exsiccatus, U. S. and B. P.) and the granulated (Ferri 
Sulphas Granulatus, U. S.), each of which is given in the dose of 3 
grains (0.2). 

Wines of Iron. 

The bitter wine of iron, no longer official, is useful as a bitter tonic 
in anemia in both children and adults, and may be advantageously 
accompanied with cod-liver oil. It is given in the dose of 1 to 2 
fluidrams (4.0-8.0) or more. This wine is composed of soluble citrate 
of iron and quinine, tincture of sweet orange peel, syrup, and stronger 
white wine. 

Vinum Ferri Citratis, B. P., is composed of the citrate of iron and 
ammonium, tincture of sweet orange peel, syrup, and white wine. 
The dose is identical with that of the bitter wine, and it is used for 
the same purposes. 

The plaster of iron (Emplastrum Ferri) is prepared from the 
hydra ted oxide of iron. 

The Liquor Ferri Acetatis, B. P., is given in the dose 5 to 15 minims 
(0.3-1.0). 

Untoward Effects of Iron.— Iron is apt to cause gastric distress and 
frontal headache in persons who are susceptible to its use. Even one 
dose will cause this trouble in some patients. In many instances the 
frontal headache will be found to be due to the constipation which has 
been brought on by the iron, and will be relieved if mild laxatives or 
purges are used. The state of the bowels should always be inquired 
into when iron is being used, and laxatives given whenever constipa- 
tion is present. In rheumatic and gouty persons frontal headaches 
are a common symptom when iron is given, and purgatives will not 
generally give relief. Garrod and Haig have shown that iron 
decreases the elimination of uric acid, and they think this may account 
for the production of headache in the case of rheumatic patients under 
its influence. Sometimes salts of iron produce vesical irritation and a 
constant desire to urinate, causing mucus to form in abnormal amount 
in the bladder. In children its use may result in nocturnal incon- 
tinence of urine. 

JALAP. 

Jalap (Jalapa, U. S. and B. P.) is the tuberous root of Exogonium 
purga (Ipomcea Purga, B. P.), a native of Mexico. It contains two 
resins, jalapin and convolvulin, neither of which is used in medicine 



344 DRUGS 

by itself, though both of them enter into the resin of jalap of the 
U. S. P. The term jalapin is sometimes employed to designate the 
resin. Jalap root should contain not less than 7 per cent, of total 
resin, of which not more than 15 per cent, should be soluble in ether. 

In overdose, jalap or its resin causes vomiting and purging, with 
gastro-enteritis. 

Therapeutics.— Jalap is used in medicine as a hydragogue purge to 
relieve dropsy of any origin. It may be used to deplete in cases of 
general plethora with cerebral congestion, and owing to its tastelessness 
is a useful active cathartic if given in the proper dose— namely, 1 
to 2 grains (0.06-0.12) in \ ounce (16.0) of syrup of rhubarb. Com- 
bined with calomel, it is preferred to all other purges by some practi- 
tioners, particularly if the liver is torpid. Jalap in large doses must 
be used with caution in persons who are feeble, and it is contra- 
indicated in cases suffering from gastric or intestinal irritation. 

Administration.— Jalap may be given in the form of the compound 
powder (Pubis Jalapce Compositus, U. S. and B. P.), dose 15 to 40 
grains (1.0-2.6), which is composed of 35 parts of jalap and 65 parts 
of bitartrate of potassium; and the resin (Resina Jalap®, U. S. and 
B. P.), dose for an adult 2 to 4 grains (0.12-0.25). Owing to the 
small size of the dose of the resin and its lack of taste, this prepara- 
tion is to be preferred for children in the dose of i to J grain (0.015- 
0.03). The tincture (Tinctura Jalap®, B. P.) is given in the dose of 
J to 1 fluidram (0.2-4.0); the extract (Extractum Jalap®, B. P.) is 
used in the dose of 2 to 8 grains (0.12-0.48). 

JEQUIRITY. 

This is a plant known as Abrus precatorius, the seeds of which are 
poisonous when applied to a wound. An active principle, abrin, is 
composed of paraglobulin and a-phytalbumose, which closely resemble 
snake-venom in their action. Jequirity is never used internally in 
medicine in the United States. An infusion of the powdered seeds, 
made by adding \ a dram to an ounce (2.0-32.0) of water at 104° F., 
may be painted with a brush on the inside of the eyelids in cases of 
chronic granular conjunctivitis, in order to produce an acute diph- 
theritic inflammation that will so change the chronic process present 
as to permit of cure. If an excessive action is developed, it may be 
controlled by hot compresses made of very dilute solutions of corrosive 
sublimate. The solution of the drug undergoes decomposition with 
great rapidity, and should be freshly prepared each time it is used, or 
4 to 8 grains (0.25-0.5) of boric acid should be added to preserve it. 
The drug is a powerful cardiac depressant poison when injected into 
the circulation. Whether the seeds produce poisoning when swal- 
lowed is doubtful, some asserting that they cause gastro-enteritis, 
others that they are harmless. Probably much depends on the activity 
of digestion and absorption at the time of ingestion. 



KINO 345 



JUNIPER. 



Juniperus is the fruit or berry of Juniperus communis, an evergreen 
of Northern Europe and America. It contains a volatile oil and an 
amorphous principle, juniperin. 

Physiological Action.— Juniper acts as a gastric stimulant and tonic, 
as a mild diaphoretic if combined with alcohol, and as a marked stimu- 
lating, exciting diuretic. It escapes from the body by the kidneys. 

Therapeutics.— Juniper is valuable as a stimulant to the genito- 
urinary tract whenever it is depressed or chronically diseased, as in 
chronic pyelitis, nephritis, and chronic catarrh of the bladder. In con- 
gestion of the kidneys, particularly that due to feeble circulation, if not 
accompanied by active renal changes, it relieves these organs and 
does away with albuminuria. Used after an attack of acute Bright' 's 
disease when reaction has set in and the secreting epithelium of the 
kidney is atonic, it is of value; but care should be taken that all 
inflammation has passed by or it will make the patient worse. In the 
later stages of scarlet fever, in which the renal condition corresponds to 
that just described, juniper is also useful. In old persons a sensation 
of weight across the lumbar region is often quickly removed by the use 
of juniper if the kidneys are inactive. 

Administration,— Juniper is used in the form of the compound 
spirit (Spiritus Juniperi Compositus, U. S.), composed of the oils of 
juniper, caraway, and fennel, combined with alcohol and water, in the 
dose of 1 to 4 drams (4.0-16.0). Gin is virtually identical with the 
compound spirit. The infusion of juniper is made by adding an ounce 
(30.0) of the berries to a pint (480 cc) of boiling water and allowing it 
to stand in a warm place for an hour. The entire quantity is to be 
taken in twenty-four hours. This infusion is often combined with an 
ounce (30.0) of acetate of potassium or of the bitartrate of potassium 
in the treatment of dropsy. The spirit (Spiritus Juniperi, U. S. and 
B. P.) is given in the dose of 30 minims to 1 dram (2.0-4.0). B. P. 
dose 5-20 minims (0.3-1.3). The oil (Oleum Juniperi, U. S. and B. 
P.) is used in the dose of 1 to 4 minims (0.06-0.25). 

KAOLIN. 

Kaolin (Kaolinum, U. S. and B. P.) is a soft white powder, a 
decomposition-product containing feldspar. It is used externally as 
a dusting-powder in eczema. Cataplasma Kaolini (U. S.) is used as a 
poultice. 

KINO. 

Kino (U. S. and B. P.) is the inspissated juice of Pterocarpus mar- 
supium, a tall tree of India. It contains kinotannic acid, and is used 
as ah astringent in the treatment of serous diarrhea. It is official in 
the form of the tincture (Tinctura Kino, U. S. and B. P.), and is 
given in the dose of 2 fluidrams (8.0), f to 1 fluidram (2.0-4.0), B. P. 



346 DRUGS 

Kino may be used as a gargle in sore-throat and for relaxation of the 
uvula. Under the name of compound powder of kino (Pubis Kino 
Compositus, B. P.) an efficient and pleasant antidiarrhea powder is 
used. This powder is not official in the U. S. P. The formula for 
each powder is 15 grains (1.0) of powdered kino, 4 (0.2) of powdered 
cinnamon, and 1 (0.06) of powdered opium. 

LACTIC ACID BACILLUS. 

Various strains of the lactic acid bacillus have been introduced 
into medicine during the last few years for a ^number of purposes, of 
which one of the most important is the control of intestinal putrefac- 
tion of proteids. Claims have been advanced to the effect that a 
panacea has been found for all digestive disorders, and that the uni- 
versal disease, old age, can be postponed by the constant ingestion of 
these organisms, it being thought the changes of old age are caused in 
large part by the absorption into the blood-stream of intestinal 
toxins. Like many other deductions of a sweeping character, this 
view has a small amount of truth as a basis for its existence. As a 
matter of fact, the internal use of lactic acid bacilli is of value in 
intestinal putrefaction only in those cases in which the decomposi- 
tion of proteids is the chief condition, and their employment is of no 
value, and, indeed, may be worse than useless, in cases suffering from 
fermentation of the carbohydrates; a state often increased by the 
introduction of the lactic acid bacillus. 

A differentiation of these two conditions can be made in part by 
regulation of the diet and by several methods of examination. When 
proteids are undergoing putrefactive changes the stools are alkaline 
whereas, the starches, when fermenting, usually produce acid stools. 
Another method of differentiation is by means of Strasburger's fermen- 
tation apparatus. About 5 grams of feces are placed in the lower 
receptacle of this apparatus and the tube directly above filled with 
water. The whole apparatus is then exposed to a temperature of 100° 
F. for about twenty-four hours, and the amount of gas produced is 
calculated by the quantity of water forced into the third tube. If 
more than one-third of this tube is filled with water and if the feces 
give a distinctly acid reaction, it is fair to assume that the decomposi- 
tion in the intestines is due to fermentation of carbohydrates, which 
contraindicates the use of the lactic acid bacillus. 

The second method is to Gram-stain cover-glass preparations coun- 
terstained with neutral red. In healthy stools the Gram-negative 
organisms will be present in greatest numbers; the colon bacillus being 
Gram-negative; whereas, in the presence of putrefaction, the blue- 
stained organisms are in excess. In other words, when the blue- 
stained organisms are in excess, the administration of the lactic acid 
bacillus will probably produce advantageous results, and at the same 
time meats must be strictly excluded from the diet. 



LANOLIN 347 

The explanation of the good results obtained by this plan of treat- 
ment lies in the fact that this bacillus produces lactic acid, which 
exercises a deleterious effect upon those organisms which fare badly 
in the presence of an acid medium, as, for example, the bacillus coli, 
the spirillum of cholera, the streptococcus, the bacillus typhosus, and 
others often found in the intestine. 

In addition to their use in the states first named, the bacillus lactis 
has been used in the treatment of those types of infantile diarrhea 
in which putrefactive changes are present in the bowels, and usually it 
is given to such patients in the form of diluted buttermilk. The bacil- 
lus lactis is also used in cases of rheumatoid arthritis, in which state it 
is believed that septic or bacterial absorption from the bowel is respon- 
sible for the state of the joints. 

In addition to their use internally, these organisms have been used 
locally to combat various septic states, such as slowly healing infected 
surfaces, sinuses, and even in infections due to the gonococcus, particu- 
larly the chronic types in women. One way of employing them is in 
the whey of milk curdled by their action. If the vaginal discharge is 
alkaline the commercial tablets, containing the bacillus in nearly pure 
culture, may be crushed and rubbed up into a powder with sugar of 
milk, which is then dusted over the parts affected after they have been 
thoroughly cleansed by saline solution, but not by antiseptic solutions, 
which will destroy the bacillus lactis. 

The Bulgarian lactic acid bacillus (Bacillus Bulgaricus) seems to 
be the most effective for internal and external use. It is put up in 
compressed tablets; when given by the mouth the dose is 2 or 4 tablets 
after meals, followed by a little sugar to aid its growth (see Butter- 
milk). These may be given powdered and mixed with water to 
infants. It is essential for the preservation of the bacillus that these 
tablets be kept in a refrigerator or other cool container. (See Cholera 
Infantum.) 

LANOLIN. 

Lanolin is the Adeps Lana Hydrosus, U. S. and B. P., a fat con- 
taining not over 30 per cent, of water derived from the wool of the 
common sheep, and is a whitish substance of peculiar stability, very 
difficult of saponification, and incapable of becoming rancid. Unna 
states that ointments of acids, hydrogen peroxide, and other sub- 
stances may be made by it. One great objection to lanolin is its 
stickiness, which is avoided by adding one-third of vaseline. Lanolin 
is supposed to possess very remarkable penetrating powers when 
applied to the skin in cases where much infiltration is present, particu- 
larly if it is combined with resorcin or some similar medicament. In 
itself it has little curative power, and is but little better than lard, 
suet, or any common fat as a basis for ointments. In some rare cases 
it causes irritation of the skin. Adeps Lan&, U. S., is anhydrous 
wool-fat. 



348 DRUGS 



LEAD. 



Plumbum, or lead, is a metal possessing more or less influence over 
the organism according to the salts which are employed. It is not 
official as lead itself 

Physiological Action. —Lead, in one of its soluble salts, if applied 
to a mucous membrane, by reason of its astringent effect produces a 
blanching which is particularly noticeable where the blush of inflam- 
mation has previously been present. It has little effect when given in 
a single dose, except by an indirect influence over the circulation, 
nervous system, or respiration. (For a description of the effects of 
lead in overdoses see "Poisoning," below.) 

The most irritant and poisonous of the soluble salts is the nitrate, 
the next the subacetate, and the least poisonous of the soluble salts is 
the acetate. 

The insoluble salts rarely cause acute poisoning, but frequently 
produce chronic plumbism 

Acute Poisoning. —When the acetate of lead is taken in poisonous 
amounts it produces a sweet metallic taste in the mouth, followed by 
pain in the epigastrium and the vomiting of white, milky-looking 
liquids or white curds mixed with food. The white color is due to the 
presence of chloride of lead formed by the acid of the gastric juice. 

The pain rapidly increases in severity, and diarrhea due to gastro- 
enteritis may be set up, or, in other cases, obstinate constipation is 
present. The passages are generally black, this color being due to the 
presence of the sulphide of lead. At the same time the pulse becomes 
rapid, tense, and cord-like, but after a time weak and compressible. 
The face is anxious and pale or livid. The thirst is excessive and 
cramps in the calves of the legs or muscular twitchings may ensue. It 
is said that the blue line on the gums characteristic of chronic poison- 
ing may occur in acute poisoning, but this is rarely, if ever, seen. If 
coma comes on in the course of acute lead-poisoning, death is almost 
certain. 

The treatment consists in the use of the chemical antidote, a soluble 
sulphate, in large quantity, in the administration of emetics, and the 
use of the stomach-pump if the vomiting produced by the drug is 
not sufficient to rid the stomach of all the poison. The best soluble 
sulphates to employ are Epsom and Glauber salts, because they are 
always at hand, are readily soluble, and, in excess, act as purges which 
will wash out the intestinal canal. Hot applications should be applied 
to the belly and feet, and the pain and irritation which are present 
should be relieved by opium. 

Chronic Poisoning.— Chronic lead poisoning is rarely produced by 
the soluble salts of lead, nearly always being due to the insoluble salts. 
The symptoms of chronic lead poisoning, or plumbism, are as various 
as it is possible to find variety in the signs of disease of every kind. 
There is no train of symptoms which may not occur, and the occur- 



LEAD 349 

rence of rare, anomalous symptoms in a given case should at once 
bring to the mind of the physician the thought of lead poisoning or 
syphilis. Chronic poisoning occurs in painters, manufacturers of lead 
salts, and every one who is largely brought in contact with the metal 
in the arts. It occurs from the use of hair-dyes containing the acetate 
of lead, from drinking water which has passed through new lead pipe, 
and even from the biting of silk threads weighted with salts of lead. 
Chromate of lead has been used to color sponge-cake when eggs were 
thought too expensive for the purpose, and has killed many persons. 
Millers who have filled the holes in grindstones with lead have caused 
widespread epidemics of what has been called "dry cholera," and 
many persons have suffered from lead poisoning from eating apple- 
butter kept in jars glazed with lead. 

One of the most prominent, but by no means the most constant, 
symptoms of chronic plumbism is bilateral wrist-drop, due to palsy of 
the extensor muscles of the forearm. The short extensor of the 
thumb generally escapes the drug's influence, as does also the supi- 
nator longus. Foot-drop also occurs, and I am indebted to Dr. H. C. 
Baldwin, of Boston, for the accompanying illustration of this state. 

Sometimes internal squint arises from paralysis of the external rectus 
muscles by the lead. Another very common symptom is severe colic 
centering around the umbilicus and radiating through the belly and 
loins. Obstinate constipation often accompanies these symptoms, 
and the feces, when passed, are white and clay-colored, owing to 
deficient secretion of bile. During an attack of lead colic the arterial 
tension is increased very markedly, the tongue is coated and whitish, 
and the bowels are obstinately confined. 

If these early warnings are disregarded and the exposure to the lead 
is continued, cerebral symptoms may come on, the result of encepha- 
lopathia saturnina, or saturnine cerebritis. Saturnine epilepsy is not 
very rare. If convulsions come on, death generally ensues. The con- 
vulsions in some cases are not due to a cerebral effect of the lead, but 
to uremia due to the renal changes which it has caused. 

Renal disease is very commonly produced by lead, and it is not un- 
common for chronic contracted kidney to be found at the autopsy of 
a sufferer from chronic lead poisoning. If a patient with chronic lead 
poisoning have a urine with a persistent low specific gravity, the prog- 
nosis is grave, as evidencing advanced kidney involvement. 

Asthma due to the inhalation of lead-dust is sometimes met with. 

The most important confirmatory evidence of chronic lead poisoning is 
a blue line on the gums just where they join the teeth. Its absence is 
not a negative sign, however, as poisoned persons cleanly in respect to 
their mouths often do not have it. This blue line is not, however, 
pathognomonic, as Oliver states that persons who have received large 
doses of bismuth by the mouth, or by injection into an empyema, 
may show a similar line. Basophilic degeneration of the red blood 
cells separates the two conditions. Marked cachexia or anemia is com- 



350 



DRUGS 



monly seen in chronic lead poisoning. Not only is basophilic degen- 
eration of the red blood cells met with in chronic lead poisoning, but 
McJunkin has shown that leukocytes and endothelial cells change 
inorganic lead into a compound soluble in albuminous liquids. 

The blue line may appear early or late. Charteris reports a case in 
which it appeared after taking only 4 lead and opium pills. In 
another case it did not appear until after 128 grains had been ingested. 







%** «* 


\ 


.~ 7 




k~~* 






1 


»,-,.. 


t 




& 


r m .-r^^djjflm 


\ 


ST ' BB Mt^-' 





Fig. 52. — Drop-wrist and drop-ankle due to chronic lead poisoning. (Baldwin's case.) 



After prolonged lead poisoning the|nerve-trunks are found atro- 
phied, and finally changed into fibrous cords. Anterior poliomyelitis 
may be present, but true locomotor ataxia is rarely caused. If ataxic 
symptoms exist, they are most probably dependent on pseudo-tabes 
produced by a plumbic multiple neuritis, which can be separated from 
true tabes dorsalis by the absence of several of the important true 
tabetic symptoms— such as slow onset, the Argyll-Robertson pupil, 
etc.— while the presence of marked wasting and loss of power, and 
sometimes tenderness over the nerve-trunks, points to neuritis. 



LEAD 351 

In some cases trophic changes in the joints ensue, and plumbic gout 
is not rarely seen, or even lead arthritis, with deposits of urates in the 
joints. This condition is due to the fact, pointed out by Garrod and 
Haig, that lead forms insoluble salts with uric acid. 

Lead excapes from the body in the urine, the feces, and all secre- 
tions. It is chiefly eliminated by the liver in the bile. 

Treatment of Chronic Poisoning.— The treatment consists in 
three classes of remedial measures: (1) The removal of the cause 
(2) the removal of the poison in the body; (3) the treatment of the 
lesions produced by the poison. 

In lead colic hepatic purges, such as jalap and calomel, combined 
with opium to prevent pain, are indicated, and alum and opium or 
morphine are said to be almost specifics, the alum in 2-grain doses, the 
others in full amounts. In many cases purges fail to move the bowels 
of a person suffering from chronic lead poisoning, and succeed only 
when morphine is given to overcome the intestinal inhibition produced 
by the irritation caused by the lead. 

To aid in the elimination of the lead, iodide of potassium, which 
forms double soluble salts in the tissues with the metal, is to be used, 
10 to 20 grains (0.6-1.3) three times a day. 

If progressive paralysis is present, Wood insisted on the use of large 
doses of strychnine at the same time that iodide is given. Strychnine 
sulphate should not, of course, be given in the same mixture as the 
iodide, as it is, chemically, incompatible. 

Electricity should be used as a remedy to restore lost function. If 
the faradic current makes the muscles contract, it should be employed, 
and if not, the galvanic current should be used. Curiously enough, 
partial voluntary power sometimes returns before the muscles will 
react at all to electricity. 

It is said that baths of sulphuret of potassium do good in chronic 
plumbism, 5 or 6 ounces (180.0) of the salt to each bath, which is to be 
given in a wooden or enamel tub. The patient should afterward be 
well soaped, then thoroughly rinsed off, and rubbed down with a 
rough towel. 

As the salts of lead are used for different purposes, the therapeutics 
of each one will be taken up separately. 

Acetate of Lead. 

Acetate of lead (Plumbi Acetas, U. S. and B. P.), or sugar of lead, 
has a sweet, astringent taste, and is soluble in water, but the solution 
formed is slightly milky in appearance. 

Therapeutics.— Acetate of lead may be used, and is largely employed 
in the following pill in the treatment of serous diarrhea: 

1$ — Plumbi acetatis gr. xl (2.6) 

Pulveris opii gr. x (0.6) 

Camphors gr. xl (2.6). — M. 

Fiant piluls, No. xx. 

S. — One every four hours. 



352 DRUGS 

This pill may also be given in cases of dysentery. 

The acetate of lead in proportion of 1 to 8 grains (0.06-0.5) to the 
ounce of water may be used as an injection for gonorrhea. 

Lead acetate is also a useful application for the dermatitis pro- 
duced by poison ivy, as this drug precipitates the sticky, non-volatile 
oil of Rhus toxicodendron, studied by Pfaff. The acetate should 
be dissolved in alcohol in the proportion of J grain to the ounce 
(0.03-30.0) and used as a wash. After this the inflamed parts should 
be treated by cooling applications, but ointments are not to be used, 
as they dissolve the poisonous oil and spread the irritation. 

The B. P. recognizes the following preparations of lead acetate: 
Pilula? Plumbi cum Opio, dose 3 to 5 grains (0.2-0.3); Suppositoria 
Plumbi Composita, each suppository containing 1 grain (0.06) of opium 
to 3 grains (0.20) of lead acetate; and an ointment ( Unguentum 
Plumbi Acetatis). 

Carbonate of Lead. 

Carbonate of lead {Plumbi Carbonas, B. P.), or white lead, is 
insoluble, and is used as a coating or dressing for burns, scalds, or 
ulcers when rubbed up with linseed or other oil, or in the form of the 
ointment (Unguentum Plumbi Carbonatis, B. P.). If an extensive 
surface is covered with this ointment, it may cause subacute lead 
poisoning by absorption. 

Carbonate of lead may be used in the treatment of sunburn in the 
following perscription. 

J$ — Plumbi carbonatis 5J (4.0) 

Pulveris amyli 5J (4.0) 

Unguenti aquse rosse 5j (30.0) 

OleiokvEe f 5ij (8.0) — M. 

S. — Apply to the inflamed skin. 

Iodide of Lead. 

Iodide of lead (Plumbi lodidum) is occasionally employed in 
medicine; the dose is J to 2 grains (0.03-0.12). Emplastrum Plumbi 
Iodidi, B. P. and Unguentum Plumbi Iodidi, B. P., are used as external 
astringent and alterative applications, but are rarely useful. 

Liquor Plumbi Subacetatis. 

Liquor Plumbi Subacetatis, U. S., and Liquor Plumbi Subacetatis 
Fortis, B. P., or Goulard's extract, is a colorless liquid, much used 
externally, when diluted with laudanum, for sprains, bruises, and 
local inflammations, under the name of "lead-water and laudanum." 
"L. and L.," as it is often called in the hospitals, is a useful applica- 
tion in the dermatitis produced by poison ivy. The proportion should 
be 4 parts of the undiluted lead-water, diluted with 16 parts of water 
to 1 of laudanum, but this is varied as the inflammation or pain is the 



LECITHIN 353 

more severe. The official liquor is also official in a dilute solution 
{Liquor Plumbi Subacetatis Dilutus, U. S. and B. P.), and as such is 
too weak for ordinary use, although it is commonly employed. The 
strong solution should be used in the strength of from 1 to 4 ounces 
(30.0-120.0) to the pint (480 cc) of water. This solution should 
never be employed if the skin is broken, as the drug prevents healing 
by constringing the edges of the wound. 

If some bread-crumbs be saturated with the solution just named and 
applied to an inflamed finger, a felon can often be aborted in its early 
stages. The official dilute solution is useful as a lotion in eczema 
which itches and tingles and is not dry in character. It should be 
applied once or twice a day, and it is well to follow the application of 
lead with an alkaline wash. (See Eczema.) 

Lead-water is also useful in pruritus pudendi. The cerate (Ceratum 
Plumbi Subacetatis, Unguentum Plumbi Subacetatis, B. P.), and the 
glycerin {Glycerinum Plumbi Subacetatis, B. P.) may be used for 
the same purposes as Goulard's extract. 

Lead acetate is used for the preparation of lead plaster {Emplas- 
trum Plumbi, U. S. and B. P.), sometimes called "diachylon plaster." 

Hebra recommended for sweating of the feet an application of equal 
parts of lead plaster and linseed oil, applied on linen and wrapped 
around the feet every third day. 

It is interesting to note that in England this plaster has been freely 
applied to produce abortion by the absorption of the lead with result- 
ing poisoning. 

Litharge. 

Litharge {Plumbi Oxidum, U. S. and B. P.) is used in the preparation 
of the solution of subacetate of lead. 



LECITHIN. 

Lecithin is found chiefly in those parts of the brain substance which 
contain the largest amount of phosphorus, but it also occurs all 
through the animal body in many cells. The lecithin found on the 
market is, however, derived from the yolk of eggs. It is soluble in 
alcohol, ether, chloroform, and fatty oils, and occurs as a yellowish- 
white mass. 

Lecithin is used in cases of neurasthenia and in tuberculosis when 
the nervous system is feeble and the patient exceedingly atonic. It 
has also been used as a tonic in all states characterized or accompanied 
by nervous exhaustion in rickets, and in exophthalmic goiter. In neu- 
rasthenia and in cases of exophthalmic goiter it is said to not only pro- 
duce marked improvement in the general state of nutrition but also 
to act as a nervous sedative. Lecithin is perhaps the most powerful 
substance we have to increase leukocytosis, often doubling or tripling 
the number of the leukocytes. Unfortunately its taste is very dis- 
23 



354 DRUGS 

agreeable to many patients. It may be given in alcoholic solution or 
pill in the dose of 3 to 5 grains (0.2-0.3) three times a day after meals. 
It is usually wise to have the patient take considerable quantities of 
milk to aid nutrition. If the stomach is out of order, the dyspeptic 
symptoms must be overcome, if possible, before the lecithin is given. 

LEPTANDRA. 

The medicinal portion of Veronica virginica is the rhizome and 
rootlet, from which are made the extract of leptandra (Extr actum 
Leptandrw) and the fluidextract {Fluidextractum Leptandra'). The 
dose of the solid extract is from 1 to 8 grains (0.06-0.5) and of the 
fluidextract 5 to 40 minims (0.3-2.6). 

Physiological Action. —Very few experiments have been made as 
to the action of this remedy, and the only ones of importance are 
those of Rutherford and Vignal, who found that it possesses a moder- 
ate influence in increasing the flow of bile. In overdose it causes 
violent purging. 

Therapeutics.— Preparations of leptandra, which are not so active 
as is the fresh drug, are excellent substitutes for calomel, according 
to many clinicians. Those who have used leptandra also believed 
it to be of the greatest value in the indigestion of the intestinal type 
sometimes called " duodenal atony." (See also Podophyllum) The 
following pill is a good method of using the drug in these cases: 

1$ — Extracti chiratse . . gr. xx (1.3) 

Extracti leptandrse gr. xx (1.3). — M. 

Fiant pilulse, No. x. 

S. — One pill after each meal. 

Under the name of leptandrin we have an impure resin which is 
given in the dose of 2 to 5 grains (0.12-0.3). An alkaloid of doubtful 
existence is called leptandrine. 

LEVULOSE. 

Levulose is a monosaccharide sweeter than cane-sugar, and if pure, 
free from glucose. It is used in medicine as a substitute for sugar in 
the dietetic treatment of diabetes and tuberculosis, and is absorbed as 
levulose and is readily oxidized in the body. Levulose may be taken 
by diabetic patients in the dose of 1 to 2 ounces a day without injury 
in many instances, and tends to promote nutrition but in some cases 
it does no better than sugar. It has also been used with advan- 
tage in poorly nourished children and by tuberculous persons whose 
digestion cannot cope with cane-sugar. In post-anesthetic chloroform 
poisoning and in threatened diabetic coma it may be given intra- 
venously or by the Murphy drip. (See Intravenous Injections and 
Enteroclysis, Part III; Diabetes, and Vomiting, Part IV.) When 
given by the vein the dose is about 1 ounce (30.0) to an adult, dis- 



LIQUOR POT A SSI I HYDROXIDI 355 

solved in 1 quart (1000 cc) of normal salt solution. When given by 
the rectum it is dissolved in plain water in the strength of J ounce 
(15.0) to 1000 cc to get good results. 

LIQUORICE. 

Liquorice (Glycyrrhiza, U. S., and Glycyrrhizce Radix, B. P.) is 
the root of Glycyrrhiza glabra, or glandulifera a plant of Southern 
Europe and Asia. The solid extract is used to increase secretion 
in the mouth, and when dissolved in water to form a vehicle for other 
drugs. The powdered solid extract is a very mild and useful laxative. 

Administration.— The solid extract {Extraction Glycyrrhiza, U. S. 
and B. P.) is used in a dose varying from 5 to 120 grains (0.3-8.0). 
The pure extract (Extractum Glycyrrhiza? Purum, U. S.) is used 
in the same quantities as the ordinary extract. The fluidextract 
(Fluidextractum Glycyrrhiza?, U. S.) or the liquid extract (Extractum 
Glycyrrhizce Liquidum, B. P.) is used in 1- to 2-dram (4.0-8.0) doses, 
and enters into the preparation of the elixir (Elixir Glycyrrhiza?, 
U.S.). Under the name of Brown Mixture, or " Compound Liquorice 
Mixture," a very efficient expectorant solution is official (Mistura 
Glycyrrhiza? Composita, U. S.), which contains as its most important 
ingredients 120 parts of paregoric, 0.24 gram of tartar emetic, and 
30 parts of sweet spirit of nitre, so that half an ounce of the mix- 
ture contains about ^V grain of tartar emetic. The dose of Brown 
Mixture is 1 to 4 drams (4.0-16.0). Pubis Glycyrrhiza? Compositus, 
V. S., and B. P., or compound liquorice powder, contains, according to 
the U. S. P., 18 per cent, of senna, 23.6 per cent, of liquorice, 0.4 per 
cent, of oil of fennel, 8 per cent, of washed sulphur, and 50 per cent, 
of sugar. According to the B. P. it should contain 2 parts of senna, 
2 of liquorice-root, 1 of fennel-fruit, 1 of sublimed sulphur, and of 
sugar 6 parts. The dose is 1 to 4 drams (4.0-16.0). It is largely 
used as an efficient laxative after childbirth and in cases which suffer 
from constipation chiefly due to the inactivity consequent upon being 
in bed. Finally we have Glycyrrhizinum Ammoniatum, U. S., which 
is the sweet principle of liquorice rendered soluble and easily tasted 
by the addition of ammonia. The dose of this preparation is 5 to 15 
grains (0.3-1.0). 

LIQUOR POTASSH HYDROXIDI. 

Liquor Potassii Hydroxidi, U. S.; Liquor Potassw, B. P., is a solu- 
tion of potassa containing about 5 per cent, of potassium hydroxide, 
and is a clear, odorless liquid of caustic taste and strongly alkaline 
reaction. It is used in medicine as an antacid and for the purpose 
of decreasing the acidity of the urine. Its dose is 5 to 30 minims 
(0.3-2.0) well diluted with water. 

In cases of ingrowing toe-nail it is often used to soften the nail prior 
to packing with cotton or partial evulsion. 



356 DRUGS 



LITHIUM. 



Lithium is used in several forms, but its salts may be divided into 
two classes— those which act as lithium and those which act as the 
acids forming them. In the first class are the carbonate (Lithii 
Carbonas, U. S. and B. P.), dose 2 to 10 grains (0.12-0.6), 2 to 5 
grains (0.12-0.3), B. P., the citrate (Lithii Citras, U. S. and B. P.), 
dose 5 to 20 grains (0.3-1.3), 5 to 10 grains (0.3-0.6), B. P. In the 
second class are Lithii Bromidium, U. S., dose 10 to 30 grains (0.6- 
2.0), and Lithii Salicylas, dose 10 to 30 ; grains (0.6-2.0). 

The carbonate and citrate are used in gout and rheumatoid arthritis 
for the purpose of entering into combination with the uric acid in the 
body to form soluble urates and prevent deposits in the joints. They 
have been said to dissolve calculi, but this is untrue, though they 
are used when it is desired to render the urine alkaline. Haig has 
pointed out that although lithium forms salts with uric acid in the 
test-tube, in the body they have a greater affinity for the acid sodium 
phosphate in the blood, and practically leave the uric acid to itself. 
This is an important point, since it proves that the large amount of 
water generally taken with lithium salts has more to do with relieving 
gout than has the lithia. The carbonate is not soluble in water, 
and should be given in capsule or freshly made pill, but the citrate is 
soluble. The latter may be made from the former by taking 50 
grains (3.5) of the carbonate, 90 grains (6.0) of crystallized citric acid, 
and warm distilled water 1 fluidounce (30.0). The acid should be 
dissolved first, and the carbonate added to the solution. The solution 
should then be kept hot until effervescence ceases. 

In cases of diabetes depending upon a gouty taint excellent results 
are said to be obtained from the use of the citrate or carbonate of 
lithium and arsenic. The dose should be ■%■-$ grain (0.002) of arsenate 
of sodium and 10 grains (0.6) of the lithium salt three times a day. 

It is worthy of note that in some cases citrate of lithium will dis- 
order the stomach and produce vomiting; and overdoses produced 
general relaxation of the system with a sense of feebleness. 

(For the use of other salts of lithium see the articles on the Bro- 
mides, Salicylic Acid, and Benzoic Acid. See also article on Mineral 
Springs.) 

LOBELIA. 

Lobelia, U. S. and B. P., is the leaves and tops of Lobelia inflata, 
a common weed of the United States. It contains an alkaloid, lobe- 
line, and lobelic acid. 

Physiological Action.— When taken in overdose lobelia causes erne- 
sis, intense prostration, a feeble pulse, pale skin, livid face, muscular 
relaxation and a cold sweat. Violent purging may be present. It is 
said to paralyze the motor nerve-trunks, and it causes a fall of arterial 
pressure, followed by a rise, the latter change being due to the 



LUMINAL 357 

asphyxia which it finally produces. Ultimately it paralyzes the respi- 
ratory center and the peripheral vagi. The treatment of the poison- 
ing is to administer opium to allay irritation and check vomiting, 
to give alcohol and ammonia to support the heart, and the use of 
external heat. 

Therapeutics.— Lobelia is used chiefly as an antiasthmatic, and has 
been equally praised and condemned by eminent authorities. The 
reason for this lies in the fact that it is often useless in asthma unless 
given in almost poisonous dose. Wood taught that it should never 
be used, because of its poisonous effects even in doses medicinally 
active, while Sydney Ringer stated that the drug is erroneously 
thought to be dangerous. In asthma both of the gastric and bron- 
chial form lobelia is undoubtedly of service. In some cases it fails 
as signally as it succeeds in others. If the asthma is due to or 
associated with cardiac disease, lobelia should never be employed. 
The drug should be taken in the dose of f dram (2.0) to 1 dram 
(4.0) of the tincture at the first sign of an attack, or in 10-minim (0.6) 
doses every fifteen minutes until distinct nausea occurs or relief is 
obtained. If the heart is feeble, its use is contraindicated. 

In atonic constipation with great dryness of the feces 10 minims (0.6) 
of the tincture of lobelia at bedtime are often of service, particularly 
if it is combined with cascara sagrada. (See Cascara Sagrada.) 

Administration.— Lobelia is given in the form of the tincture 
(Tinctura Lobelice, U. S.), in the dose of 10 to 60 minims (0.6-4.0) 
as a sedative, or 2 to 4 drams (8.0-16.0) as an emetic. The vinegar 
(Acetum Lobelia) is no longer official, but is given in the dose of 
20 to 30 minims (1.3-2.0), and the fluidextract (Fluidextr actum 
Lobelia, U. S.) in the dose of 1 to 5 minims (0.06-0.3), or as an emetic 
in the dose of 15 minims (1.0). 

In the form of the infusion lobelia is useful as a lotion in the treat- 
ment of the dermatitis produced by poison ivy. The proportion used 
should be an ounce (30.0) to the pint (480 cc) of water. 

The preparation of the B. P. is Tinctura Lobelia Mtherea, dose 
5 to 15 minims (0.3-1.0). 

LUMINAL. 

Luminal or Phenolbarbital or Phenyl-ethyl-barbituric acid differs 
from barbital in that one ethyl group has been supplanted by one 
phenyl group. It decreases respiratory frequency but is said to in- 
crease the depth of each respiration and is eliminated by the kidneys 
in large part unchanged. In poisonous dose it kills by respiratory 
failure, but recovery after taking 60 grains is reported. Its chief 
use is to produce sleep in nervous insomnia and act as a sedative 
in marked nervous excitement. It is also very valuable in epilepsy. 
(See Part IV.) The dose is from 1 to 2 grains (0.06-0.13). Three 
grains is the maximum dose. As it is insoluble in water it is 
best given in tablet or capsule. Luminal sodium or phenolbarbital 



358 DRUGS 

sodium is much more soluble in water and may be given in 20 per 
cent, solution if need be by the hypodermic needle in the dose of 1 
to 2 grains, or by the mouth in the dose of 2 to 8 grains (0.12-0.5), 
although the latter amount is rarely needed. 

LYCETOL. 

(See PlPERAZINE.) 

LYCOPODIUM. 

Lycopodium, U. S., is a pale-yellow powder derived from Ly co- 
podium clavatum, a species of moss. It is used by pharmacists as a 
powder in which to roll pills, and by physicians and nurses to prevent 
the intertrigo or chapping of the skin of infants and adults. 

LYSOL. 

Lysol is a preparation made by dissolving in fat and saponifying 
with alcohol that part of tar oil which boils between 190° and 200° 
C, and is a brownish, clear, oily fluid, smelling somewhat like creo- 
sote. It is used for the same antiseptic purposes as creolin (see 
Creolin), but possesses the advantage of forming a clear, soapy 
fluid when mixed with water, in which instruments can be seen. If 
small instruments are used, the solution is so soapy that it renders 
them too slippery for ready use. Those who have used lysol claim 
that it does not affect the skin of the operator's hands except to 
render it soft and flexible. Used upon mucous membranes, a solu- 
tion of lysol should not be stronger than 2 per cent. As a gargle 
for septic sore-throat a 1 per cent, solution may be used. Liquor 
Cresolis Compositus, U. S., is similar to lysol. Lysol is much less 
poisonous than phenol, but a considerable number of cases of 
poisoning by it have been reported. 

MAGNESIUM. 

Magnesium is a metal never used as such, but always in the form 
of one of its salts, which are the sulphate, citrate, carbonate, and 
sulphite. The sulphite is a natural salt found in sea-water and in 
caves or in the water coming from the latter. The citrate and 
carbonate are derived from the sulphate. The carbonate is insoluble 
in water and alcohol. The others are soluble. 

Magnesium Carbonate. 

The carbonate of magnesium (Magnesii Carbonas, U. S.) is official 
in the form of the heavy and light powder (Magnesii Carbonas 
Ponderosus and Levis, B. P.), and these two substances do not 
differ in respect to their effects. The light magnesium is never given 



MAGNESIUM m 359 

internally because of its bulk, but it is used as a dusting-powder in 
intertrigo, and in the form of white cubes rubbed on the skin to pre- 
vent excessive perspiration and as a cosmetic. The heavy magnes- 
ium is used as an antacid, and is not, as has been thought by some, 
in any sense a laxative, as it possesses no such power. When the 
stomach or intestines contain much acid from fermentative changes, 
these acids may, however, unite with the magnesium and form a 
slightly laxative salt. 

In sick headaches due to excessive gastric acidity carbonate of mag- 
nesium is often of service. The dose of the carbonate is from 5 to 
60 grains (0.3-4.0). It should not be used constantly, as there is 
danger that it will accumulate in the intestines. 

Magnesium carbonate, by increasing the coagulability of the blood, 
may be used in hemophilia, and it is often of value in urticaria. (See 
Calcium Chloride.) 

Litfuor Magnesii Bicarbonatis , B. P., is given in the dose of 1 to 2 
ounces (30.0-60.0) as a laxative. 

Magnesium Citrate. 

The citrate of magnesium (Magnesii Citras) is a more irritating 
purge than the sulphate, but it is more agreeable to the taste. It is 
official as Liquor Magnesii Citratis, U. S., which is effervescent and 
should never be used unless freshly prepared. It is made by add- 
ing bicarbonate of potassium to a syrupy solution of the citrate of 
magnesium containing an excess of acid, and corking the bottle 
tightly, the cork being tied down with a strong cord. Care should 
be taken that the bottle is a strong one, as the development of large 
amounts of carbonic acid gas may burst it if it be weak. The dose 
is half to one bottle, w T hich contains about 12 ounces (360 cc). It 
is too irritating to be used when inflammation of the alimentary 
canal exists, but is useful in acute constipation and in sick and 
bilious headache. 

The effervescent citrate (Mag?iesii Citras Efferwscens) is less 
agreeable to take than the solution just named. It should be dis- 
solved in water, about 1 to 3 drams (4.0-12.0) of the salt being 
used in each dose, and swallowed while the solution is effervescing. 
It must be kept in bottles tightly corked. 

Magnesium Oxide. 

Magnesia is the oxide of magnesium (Magnesii Oxidum, U. S.), 
made by exposing the carbonate of magnesium to a red heat. It is 
used in the form of the light magnesia (Magnesia Levis, B. P.) as a 
dusting-powder. The troches (Trochisci Magnesia) each contain 3 
grains (0.2). Magnesii Oxidum Ponderosum, U. S., is official in the 
B. P. as Magnesia Ponderosa. 



360 DRUGS 

Magnesia is an antidote to arsenic, and when employed to precipi- 
tate a soluble preparation of iron it forms the " Antidotum Arsenici" 
{Ferri Hydroxidum cum Magnesii Oxido, U. S.). (See Arsenic.) 

It is important that the student should not confuse magnesia and 
magnesium. The first is the oxide of the second, and is sometimes 
called calcined magnesia. Magnesia and the carbonate of magnesium 
may be used interchangeably. 

"Milk of Magnesia" {Magma magnesia, U. S.) is a liquid prepara- 
tion of magnesium oxide which is deservedly popular and pleasant. 
It is an aqueous mixture which, by skilful pharmaceutical processes, 
is nearly stable. It is used as a gentle laxative, which is increased in 
effectiveness if it be followed by a little orange-juice, and to correct 
gastric irritability and acidity in both adults and children. It is also 
used as a mouth wash to neutralize acids and to protect the teeth. The 
dose varies from a teaspoonful to a tablespoonful, which may or 
may not be diluted with water. 



Magnesium Sulphate. 

Sulphate of magnesium {Magnesii Sulphas, U. S. and B. P.) is a 
very soluble white granular powder of neutral reaction and salty 
taste, and is soluble in water. It is generally known as " salts," 
although in some parts of the United States this term also includes 
the sulphate of sodium and "Rochelle salt" or the tartrate of sodium 
and potassium. 

When taken by the mouth in ordinary solutions, it is usually not 
toxic, but if injected into a vein it is very poisonous and kills by 
respiratory failure. (See Poisoning.) 

Sulphate of magnesium is a purge by reason of its abstraction of 
water from the intestinal bloodvessels, because it stimulates peri- 
stalsis directly and by reason of the fact that solutions of it are not 
readily absorbed. As a result of these three factors free passages 
are produced, the bowel being filled by the water of the original 
solution and the liquid poured out by the bowel wall. All strong 
saline solutions, above the strength of 9 per 1000, abstract liquids 
from the tissues when brought in contact with them, and therefore 
whenever a thorough purgative action is required— that is, where 
depletion of the intestine or absorption of transudations is to be 
attained— the magnesium should be given in concentrated form, so 
as to make its solution as of high a percentage as possible. 

In cases of dropsy the use of concentrated solutions is particularly 
necessary if free watery evacuations are desired, and from 1 to 2 
ounces should be given before breakfast or on an empty stomach as 
in as little water as will dissolve the salt. (See Dropsy.) Generally 
it is better to give this quantity divided into small doses every fifteen 
minutes until it is all taken. These concentrated solutions are safe if 



MAGNESIUM 361 

the tissues are water-logged, but dangerous if they are not. (See 
Poisoning.) 

In enteritis and peritonitis the use of magnesium sulphate has 
largely ceased. It is claimed to be better than ipecac in the treat- 
ment of bacillary dysentery. When used for the latter purpose it 
should be given in dram (4.0) doses of a saturated solution with 
10 to 15 drops (0.6-1.0) of aromatic sulphuric acid every two hours. 
The sulphate is not irritating, and may be given freely when inflam- 
mation exists. 

Magnesium sulphate forms a large part of most of the natural 
purgative waters, but in them is present in very dilute form. These 
waters act partly by supplying the contents of the bowel with fluid 
and thereby softening the feces, the solution not being absorbed 
because of the salt contained in it. 

Sometimes severe attacks of renal pain occur in middle-aged persons 
who have frequent attacks of gravel, and the urine will be found 
to contain octahedral crystals of calcium oxalate. A useful treat- 
ment is to give | to 1 dram (2.0-4.0) of magnesium sulphate with 
equal parts of citrate of potassium twice or thrice a day, in water, 
for a considerable period of time. 

Magnesium sulphate may be given by enema with the double 
purpose of unloading the bowels and acting as a depletant. The 
best mixture for this purpose seems to be that of Watkins— namely, 
2 ounces (60.0) of magnesium sulphate, 1 ounce (30.0) of glycerin, 
and 4 ounces (120.0) of water. The B. P. contains an official prepa- 
ration called Magnesii Sulphas Effervescens, which is granulated, and 
is given by the mouth in the dose of 4 to 8 drams (16.0-32.0). 

Tucker has shown that magnesium sulphate acts as a powerful 
pain reliever and local anesthetic if applied locally in saturated solu- 
tion by means of compresses. For this purpose it may be applied 
over the scrotum in orchitis and over neuralgic nerves. I have relieved 
the pain of neuritis in the foot by placing a circular compress wet 
with magnesium sulphate about the leg. Used in this manner it is 
also an excellent remedy for erysipelas and to relieve the pain of 
acute inflammatory rheumatism. In the great war a saturated solu- 
tion proved an excellent dressing for wounds infected by streptococci, 
as it inhibits their growth. The efficacy of the solution is increased 
if 10 per cent, of glycerin is added to the solution. This also keeps 
the dressing moist. 

Meltzer and others have shown that the injection of magnesium 
sulphate solution into the subarachnoid space by the intraspinal 
method (see Procaine) aids materially in controlling the spasms of 
tetanus and often causes sleep, although, of course, it does not cure. 
Meltzer used by intraspinal injection 1 cc of a 25 per cent, solution 
in water to each 20 pounds of body weight of the patient. The 
patient if in severe convulsions should be chloroformed before the 
injection, and the head should be kept up so that the solution will 



362 DRUGS 

not find its way toward the vital centers. As a rule, the relaxation 
of the muscles lasts about twenty-four hours, after which the injec- 
tion is to be repeated in smaller dose and before the symptoms of the 
disease return in full vigor. This second dose is about 0.8 cc per 
20 pounds. Should the injection of the solution result in threatened 
respiratory failure, another puncture should be performed, some of 
the spinal fluid withdrawn and replaced by normal salt solution 
(see Procaine for method, Part II), which is no sooner injected than 
it is allowed to escape, and fresh saline injected to get rid of or dilute 
the magnesium solution. Meltzer also advised that the 25 per cent, 
magnesium sulphate solution should be given hypodermically three 
or four times a day in the dose of 1 to 2 cc and even goes so far 
as to advise- in very urgent cases the intravenous injection of a 6 
per cent, solution at the rate of 2 or 3 cc per minute until the symp- 
toms are alleviated or the respiration begins to be depressed. Small 
amounts of calcium chloride solution in the strength of 2.5 per cent, 
may be given intravenously if the magnesium causes respiratory 
difficulty. 

Poisoning.— Very rarely, when concentrated solutions are given to 
persons who are not dropsical, the drug is absorbed, does not purge, 
and produces systemic poisoning, particularly if the patient has been 
deprived of fluid as in severe diabetes or after excessive vomiting. 
Death may occur, preceded by suppression of urine, toxic convulsions 
followed by paralysis in some cases and not rarely severe vomiting. 
Autopsy reveals patches of redness in the alimentary canal and an 
excess of fluid in the abdominal and other serous cavities. The treat- 
ment consists in the intravenous injection of large amounts of salt 
solution to dilute the magnesium concentration in the tissues and 
blood. The salt solution may be a little less than normal, that is, 
0.6 per cent., instead of 0.9 per cent. When the magnesium is 
diluted the kidneys can eliminate it, which they fail to do if it is in 
concentrated form. 

MANGANESE. 

Manganum, or manganese, is official in the form of the black 
oxide (Mangani Dioxidum Prcecipitatum, U. S.). Under the name 
binoxide of manganese, it has been highly praised in amenorrhea 
dependent upon functional disturbance and anemia. The dose is 3 to 
5 grains (0.2-0.3) three times a day, in pill form, and the drug should 
be taken for a few days before the expected or proper date for men- 
struation. The sulphate is rarely if ever employed, but may be 
tried in malarial jaundice. The dose is 1 to 2 grains (0.06-0.12). 

MANNA. 

Manna, U. S., is the concrete saccharine exudation of Fraxinus 
ornus, a tree of Europe. It occurs in roundish masses of varying 



MERCURY 363 

size, looking somewhat like a gray-colored gum arabic. It has a 
sweet taste and odor. Sometimes the taste is a little bitter. 

Therapeutics.— Manna is the most feeble of the laxatives, and 
causes slight flatulence in some persons. In children fed by the 
bottle one of the most frequent disorders in obstinate constipation, 
and for its relief 1 to 2 drams (4.0-8.0) of the sweet variety of manna 
may be dissolved in the milk of each bottle. When given to older 
children or adults, manna is always combined with other more 
powerful drugs, chiefly to disguise their taste. It may be combined 
with advantage with rhubarb and senna, and it enters into the official 
Infusum Senna? Compositum, U. S., the dose of which is from 1 to 4 
fluidounces (30.0-120.0). 

MATRICARIA. 

Matricaria, U. S., German chamomile, consists in the flower-heads 
of Matricaria chamomilla, a European plant, possessing mild bitter 
tonic properties when given in moderate dose. In larger amounts it 
acts as an emetic and anthelmintic. In the form of an infusion of the 
strength of 1 to 2 ounces to the pint (30.0-60.0:480 cc) it has been 
largely used as a diaphoretic, and, in small doses, to prevent colic 
in teething children. 

MEDINAL. 

(See Barbital Sodium.) 

MENTHOL. 

(See Peppermint.) 

MERCUROL. 

Mercurol is a chemical compound of mercury and nuclein, and 
possesses active germicidal power over pyogenic organisms. It is 
said to be particularly destructive to the gonococcus and to be of 
value in both gonorrhea and gonorrheal ophthalmia. It does not 
coagulate albumin nor act as an irritant, and is readily soluble in 
water. In making the solution it should be placed on the surface of 
the fluid, as it dissolves best in this way. The solution for gonorrhea 
should be of the strength of \ to 1 per cent. In obstinate cases 
solutions of 2 per cent, may be needed. It is best used by injection 
into the urethra in normal salt solution. The internal dose in syphilis 
is | to i grain (0.007-0.013). 

MERCURY. 

Hydrargyrum, U. S. and B. P., mercury or quicksilver, is a heavy 
fluid metal of a peculiar color and appearance. As metallic mercury 



364 DRUGS 

it is used in medicine in the form of the ointments, gray powder, blue 
mass, the unofficial gray oil, and plaster. 

Physiological Action.— When mercury is taken into the body in one 
of its insoluble and mild preparations it may cause no evidence of its 
presence until by frequent and excessive dosage the system in general 
begins to feel its influence. The first evidences of this are to be found 
in the mouth, and consist in tenderness of the teeth when the jaws 
are firmly and quickly closed, fetid breath, sponginess of the gums, 
which finally may bleed at the slightest touch, swelling of the tongue, 
and most prominent of all, excessive salivation, a condition some- 
times called ptyalism. If the use of the drug is persisted in, all 
these symptoms grow worse. Eczema, and finally sloughs of the 
chin and chest develop as the result of the constant dribbling of 
saliva and the direct depressing effect of the drug on the tissues. The 
teeth drop out, the maxillary bones undergo necrosis, and amid a 
general melting down and decomposition of the tissues the patient 
dies. The blood is affected and becomes very thin, fluid, and poor in 
its corpuscular elements. These symptoms ensue on the use of mer- 
cury in continued overdoses, and rarely follow exposure to the drug 
in the processes of the arts. 

In the making of looking-glasses, barometers, detonators and felt 
hats, workmen are often affected by symptoms varying very widely 
in their course. In some cases the nervous system becomes chiefly 
affected. Tremors of all sorts arise, paralysis agitans is developed, 
and the results of peripheral neuritis ensue; but it is worthy of 
note that the ocular muscles are rarely involved in mercurial tremor, 
while in disseminated sclerosis nystagmus is not rare. Similarly 
the tremors of mercurial poisoning often affect the head and neck 
alone, while in paralysis agitans this is rarely the case. Chorea often 
comes on in chronic mercurial poisoning, and the occurrence of choreic 
movements in an adult should cause inquiry as to any possible 
exposure to mercury. In other cases brownish discoloration of the 
skin, resembling Addison's disease, appears. Blindness, deafness, 
sensory disturbances, such as hyperesthesia and anesthesia, may be 
developed, and localized wasting of muscles or groups of muscles may 
assert itself. In still other cases the blood becomes impoverished 
and mercurial cachexia is developed. 

Children under three years are rarely salivated by the use of 
mercury, but this is no reason for using this drug carelessly in this 
class of cases, since the other changes in the organism nevertheless 
occur. 

Absoeption and Elimination.— The rapidity of absorption and 
elimination of mercury depends to a great extent on the variety of 
it which is given. The drug in some forms is so insoluble that great 
delay in its elimination must often ensue because it is slowly absorbed. 
Several opinions are held as to the form in which mercury is absorbed. 
It is usually taught in France that the theory of Miahl is correct; 



MERCURY 365 

this is, that the mercurial preparations are transformed in the 
stomach and intestine into the bichloride, which in turn unites with 
the sodium chloride in the blood and circulates as a double chloride 
of mercury and sodium. In Germany it is taught that it forms an 
albuminate of mercury and so circulates (Henoch's theory), or that 
it forms a chloro-albuminate (Voit's theory). All these theories as 
to its absorption are open to grave criticism. As to the elimination 
of mercury, it is known to escape as an albuminate by every excre- 
tion of the body— the urine, feces, sweat, tears, milk, and saliva. 
After a single dose the drug begins to be eliminated in about two hours 
according to Byasson, and it is entirely gotten rid of in twenty-four 
hours. If, however, the doses are repeated, it gradually accumulates 
in the body, and is so slowly eliminated as to remain for almost 
indefinite periods of time, and is found deposited in all the organs. 
In other words, the doses of mercury ordinarily given are always 
large enough to produce cumulative effects. Thus while Balzer and 
Klumpke agree with Byasson as to the rapidity of elimination of a 
single dose, they find from an experimental study that the amount of 
mercury which can be eliminated by the kidneys for many weeks 
when the body is saturated with the drug is only one-sixteenth of a 
grain a day. It is evident, therefore, that after a full mercurial effect 
is produced it is well to decrease, as do most syphilographers, the 
dose of mercury and give only sufficient to maintain the effect. It is 
also evident that the plan of using iodide of potassium every now and 
again to aid in the elimination of the residual mercury is advisable. 

Contraindications.— Acute or subacute inflammation of the kidneys 
renders the continuous use of mercurial preparations dangerous and 
they should be used cautiously if continued for any length of time 
in all cases of renal disease, as mercury is a renal poison. The state 
of the kidneys should always be carefully investigated before the 
mercury is pushed. 

Therapeutics.— The employment of mercury in medicine centers 
around three great points— viz.: 1st, its value in syphilis; 2d, its 
use as a purge; 3d, its power as an antiseptic and germicide. The 
first function is fulfilled by all the mercury salts more or less per- 
fectly, the second only by blue mass and calomel, and the third by 
the bichloride and biniodide of mercury. 

As an Antisyphilitic— In syphilis mercury is to be given, not 
because the patient is in this or that stage of the disease, but because 
it destroys the Treponema pallida. Many writers have insisted that 
it ought to be employed only in the secondary stages, and while this 
is, as a general rule, correct, certain conditions may call for it at any 
time. 

The introduction of arsphenamine has in no way displaced mercury 
as an essential part of the treatment of syphilis. The best results 
are obtained by use of both. First the arsphenamine, then a course 
of mercury. The use of both drugs is well illustrated by the following 



366 



DRUGS 



table preparedby Gibbard and Harrison from records in the British 
War Office which shows the great diminution of relapses under mer- 
cury and arsphenamine as compared to the use of mercury alone. 
There is also a great reduction in the number of "sick" days. 





Total 
cases. 


ill 

fi _ 6 

M r. 
Z ^£ 

< 


Clinical relapses. 


Average time lost by 
each man in days. 


Treatment. 


3 

O 

O 


3 


o 
£ 

O 03 

O 

S-. ■« 


■- i 

a p 

s 

3 

_.S CO 

H 


fin 


'3, 
o 


GO 1 

o 
bo ^ 

.9 c 

-3 .2 

get* 


Total. 


Mercury alone .... 
Mercury and arsphenamine 


371 
152 


42.0 
23.2 


151 
6 


115 



49 



315 
6 


83.0 
3.9 


66.2 
25.2 


17.6 
15.8 


83.8 
41.0 



Of all the preparations of mercury used by the mouth in the treat- 
ment of syphilis, the protoiodide is the most popular, and deservedly 
so. (See article on Syphilis.) 




Fig. 53. — Lamp for mercurial fumigations. This lamp is made of wire gauze, and 
resembles the safety lamp of miners, thereby guarding against sudden explosions of 
the alcoholic vapors. 

Mercury is often administered by means of fumigations or inhala- 
tions both for the removal of local and general syphilitic disorders. 
The best apparatus for either purpose is one devised by Bumstead, 
and it is both simple and inexpensive. It consists of a sheet-iron 



MERCURY 367 

cup so bent that the bottom of the vessel, instead of being flat, 
projects upward into the center of the cup, thereby forming a raised 
center with a little ditch about it. The top of this projection is 
flattened, and on its apex is placed the calomel which is to be sub- 
limed. The surrounding ditch is then filled with hot water, and 
the cup placed over an alcohol flame, which disengages the vapor 
of the calomel and water. (See Fig. 53.) 




Fig. 54. — A patient prepared for the use of mercurial sublimations. A blanket 
having been pinned tightly around the neck after the patient is stripped, the fumi- 
gator shown at his feet is placed under his chair and the calomel placed on the central 
disk, as shown in the illustration. Water is in the little ditch around it and an alcohol 
lamp under it. The patient should be given a full, warm bath beforehand to cleanse 
and prepare the skin for absorption. 

^ When inhalations are used the face should be held some six or 
eight inches from the cup to permit the fumes to pass through the 
air. Under these circumstances the quantity of calomel used should 
not exceed 4 to 5 grains (0.25-0.3), and the^ mouth should be rinsed 
out to prevent mercurial stomatitis unless a local action on the 



368 DRUGS 

buccal mucous membrane is desired. Not more than eight or ten 
inspirations should be taken at one sitting. 

If general fumigations are to be practised, the patient places the 
lamp and cup with 30 grains (2.0) of calomel on it under a chair, on 
which he sits wrapped in a heavy blanket, and subjects himself not 
only to these fumes, but to a home-made Russian bath, which relaxes 
his skin and aids absorption. (See Fig. 54.) 

The hypodermic use of mercury, if proper antisepsis and care is 
practised, has great advantages. When the symptoms of syphilis 
are urgent this method is to be resorted to and it can be employed 
when arsphenamine is contraindicated. (See Arsphenamine.) At such 
times the soluble salts, as the bichloride, are to be employed. (See 
Mercury Bichloride.) When they are not urgent and the patient is 
not under constant observation or cannot be treated regularly the 
insoluble salts are used. These salts are, however, so slowly absorbed 
that they may prove too inactive or finally manifest a cumulative 
effect. 

Of the mercurial preparations which may be administered hypo- 
dermically in syphilis, the three which surpass all others are undoubt- 
edly the salicylate of mercury, bichloride of mercury, and gray oil 
(Oleum Cinereum), which was first introduced into medicine by Lang, 
of Vienna. (See Mercury Salicylate, Bichloride of Mercury, and 
Gray Oil, under Mercury.) 

In all cases the injection should be given slowly and deeply into 
some portion of the body in which the tissues are loose, as the buttock 
or the broad of the back, and the skin of the part where the injection 
is to be made should be carefully washed and sterilized by the use of 
green soap and alcohol. 

The intravenous injection of bichloride of mercury has been 
proved so dangerous as to be properly considered unjustifiable. 

It is to be recalled that the herpes seen in advanced syphilitics is 
usually made worse by mercury. Also, that headache due to syphilis, 
if due to a cerebral growth, is benefited by mercury; while that due 
to anemia and debility complicating syphilis is increased by this drug. 

As a Purge.— The employment of mercury as a purge or laxative 
having a special action on the liver is constantly resorted to. The two 
preparations used are blue mass and calomel, but the latter is more 
active. They both cause soft or watery bilious stools, according to 
the dose in which they are given. 

Much discussion has arisen as to whether mercury affects the liver, 
and whether the peculiar greenish or brownish-yellow stools produced 
by it are due to the presence of bile or mercury. 

If there is one point firmly fixed in the mind of the average practi- 
tioner of medicine, it is that the mild chloride of mercury increases 
the quantity of bile in the intestine. If such a believer is questioned 
as to whether this increased amount of biliary fluid is due to a true 
increase in secretion or simply to an increase in the flow of bile from 



MERCURY 369 

the gall-bladder, he will either state that he is unable to answer the 
question or that he believes that it is an increased secretion. 

Practically, the position of the profession in general in regard to 
the purgative influence of calomel is that the drug exercises a stim- 
ulating effect upon the biliary gland. Experimentation upon the 
lower animals by several competent observers, and studies made by 
physiological chemists, fail, however, to give much light upon this 
subject. It is held by some that calomel never acts as calomel, but 
is converted by the hydrochloric acid of the gastric juice into cor- 
rosive sublimate, and that this drug then stimulates the liver to 
increased activity. On the other hand, the best chemical investiga- 
tions show positively that the feeble acidity of the gastric juice and 
the temperature to which the calomel is exposed are not favorable 
to the conversion of a sufficient quantity of calomel into corrosive 
sublimate to account for any hepatic influence. Thus it was found 
by Rutherford and Vignal, in their well-known series of studies of 
the influence of drugs upon the secretion of bile, that if 5 grains (0.3) 
of calomel are subjected, at 100° F., for seventeen hours to the action 
of normal gastric juice, not more than -£$■ of a grain of mercuric 
chloride is produced. As calomel does not remain in the human 
stomach for more than a day at the utmost, and generally but a few 
hours, it is not likely that as much as -£=■ of a grain of mercuric chlo- 
ride is produced from the moderately large dose of 5 grains (0.3). 
In contradiction of this, Bucheim, Winkler, and others assert that 
no conversion whatever takes place at the temperature of the body, 
and Jaennel's later studies support this view. 

The other theory as to the change which takes place in calomel 
prior to its action upon the liver is that it escapes into the intestines, 
where it is decomposed and the gray oxide of mercury precipitated, 
which may, however, be held in solution by any fatty materials, 
which, being mixed with alkaline liquids, practically form soaps. 
It is thought by Wood and others that this is the more probable 
result, particularly in view of the fact that calomel acts more like 
blue mass than corrosive sublimate. Further than this, these opin- 
ions are confirmed by the fact, with which all of us are familiar, that 
the hepatic influence of calomel is much more positively asserted if 
at the same time small doses of the bicarbonate of sodium are admin- 
istered. Under these circumstances the bicarbonate of sodium 
naturally diminishes, to some extent at least, the acidity of the 
gastric contents, and also directly or indirectly tends to increase 
the alkalinity of the contents of the duodenum. 

As if to increase the complexity of the problem, the studies of 
Rutherford and Vignal seem to prove conclusively that, in the dog 
at least, mercuric chloride has a direct stimulant effect upon the 
hepatic cells; whereas calomel, while producing purgation by increas- 
ing the secretion of the intestinal glands, in no way increases the 
secretion of the bile; and this would seem to indicate that, after all, 
24 



370 DRUGS 

the influence of calomel upon the liver is due to a very minute portion 
of it being changed into corrosive sublimate. Probably the truth of 
the matter is, that we have as yet no definite scientific explanation 
of how calomel really does act. It may be that the solution of the 
problem lies in the hepatic influence exercised by the presence of 
minute quantities of corrosive sublimate, and the purgative effect 
produced by that portion of the calomel which has not been converted 
into the strong chloride of mercury. This is rendered the more 
likely in view of the fact that the corrosive sublimate has been found 
a feeble intestinal stimulant, while the calomel has been found to 
produce active purgation in dogs, without producing an increase in 
biliary flow, when the drug has been introduced into the duodenum. 

It has been suggested, too, that calomel itself may stimulate the 
bile-expelling mechanism, while the minute portion of corrosive sub- 
limate increases the secretion of the liquid; and, again, that by means 
of the purgative effect that it produces certain substances which have 
been in the intestine are immediately removed, and, as a consequence, 
a depressant influence upon the hepatic cells no longer exists. 

Quite a number of physicians have studied the effect of the various 
so-called cholagogue drugs upon the flow of bile in human beings who 
have had biliary fistula. Perhaps the best studies are those of Pfaff 
and Balch, and more recently those of Joslin, upon women with biliary 
fistula. Calomel and the bichloride of mercury seemed invariably in 
these cases to decrease rather than increase the biliary flow. Ox-gall 
was the only drug which did increase it. 

This subject also is of interest to the practical physician in rela- 
tion to the administration of calomel in compressed tablets or other 
preparations when mixed with what might be called excipients. 
Under these circumstances, if one of the excipients is bicarbonate of 
sodium the tablet after a time almost always undergoes a change and 
becomes of a gray color. Those who have used pills or tablets of 
calomel which have been kept for a long period of time seem to be uni- 
versally in accord with the statement that they have lost the hepatic 
effect which a recently prepared powder always possesses. Thus 
it has been frequently found that no biliary flow occurs under the 
use of stale tablets, whereas free bilious purging follows the admini- 
stration of freshly prepared powders. 

Calomel and blue mass are largely used in the condition known as 
biliousness, and undoubtedly give relief. (See Biliousness.) If the 
tongue is heavily coated, the breath foul, the conjunctiva a little 
icteroid, and headache is present, one of them should be employed. 
In remittent malarial fever the use of small repeated doses of calomel 
will often bring relief from the vomiting, and it should always be 
given in the treatment of malarial disease before quinine is used if 
a thorough action of the antiperiodic is to be attained, as it aids in 
the absorption of the drug. 

One of the best ways to employ all of the various forms of mer- 



MERCURY 371 

cury is in the form of triturates, which may be prepared by triturating 
10 parts of the drug with 90 parts of milk-sugar. The minute sub- 
division of the medicament aids in its efficiency, because of its more 
ready absorption. 

As a Disinfectant.— The disinfectant and germicidal power of 
bichloride of mercury and of the biniodide is well established by 
clinical experience and experimental investigation. The strength of 
the bichloride solution for antiseptic purposes may vary from 1 to 
2000 to 1 to 20,000 of water, and for disinfectant use from 1 to 500 
to 1 to 1000. (See Antiseptics.) 

In using the bichloride of mercury as an antiseptic it is necessary 
to add a few grains of tartaric acid to the solution to prevent its 
uniting with the albumin of the tissues to form an insoluble and 
useless albuminate. The same is true of the use of mercury biniodide. 

As an Antiphlogistic— Formerly it was the belief of a large 
number of physicians that mercury possessed distinct antiphlogistic 
power in the early stages of acute sthenic inflammations, particularly 
if they involved serous membranes. It was the custom to administer 
full doses of calomel guarded with opium when traumatic meningitis 
was feared, and in endocarditis, pericarditis, pleuritis, and peritonitis 
its use was largely resorted to. More recently this plan of treatment 
has become almost obsolete, not because any deleterious effects have 
followed its use, but apparently as a matter of fashion. The writer 
believes that this is a mistake and that in acute inflammations in 
sthenic individuals in the early stages of disease mercury may do 
good. 

Leaving the general subject of mercury, we may now consider each 
individual preparation. 

Ammoniated Mercury. 

White precipitate, or ammoniated mercury of the strength of 10 
per cent, with lard {Hydrargyrum Ammoniatum, U. S. and B. P.), is 
used in an ointment (Unguentwn Hydrargyri Ammoniati, U. S. and 
B. P.) in various skin affections, when a stimulating application is 
needed, as, for example, in psoriasis and chronic dry eczema. It is 
also sometimes employed as a parasiticide in cases of tinea. The 
official ointment should generally be diluted with lard, as it is far too 
strong and will often induce a dermatitis if used undiluted. 

In ozena, whether syphilitic or not, Trousseau has recommended 
the employment of the following powder as a snuff: 

1$ — Hydrargyri ammoniati gr. iv (0.25) 

Pulveris sacchari albi 5ss (16.0). — M. 

S. — To be used as a snuff, after thoroughly blowing the nose. 

The red precipitate may be used instead of the white. The treat- 
ment removes the stench and may cure the complaint. It may, 



372 DRUGS 

however, irritate the mucous membrane, in which case it should 
be used in the strength of 2 grains to | ounce (0.12-16.0). Ammo- 
niated mercury is never used internally. 

Bichloride of Mercury. 

Corrosive mercuric chloride, or corrosive sublimate (Hydrargyri 
Chloridum Corrosivum, U. S.; Hydrargyri Perchloridum, B. P.), is an 
exceedingly poisonous and irritating substance when taken internally 
in concentrated form. 

Taken internally in poisonous dose, it causes violent pain in the 
stomach, vomiting, purging of mucus, blood, and the contents of 
the intestine, collapse, and suppression of urine. The patient should 
be made to swallow large quantities of the antidote, white of egg, the 
stomach should be repeatedly washed out with warm milk by the 
stomach-pump, heat should be applied about the body, and the 
proper stimulants be given hypodermically if the pulse Or respiration 
fail. If death does not occur within a few hours the gastro-intestinal 
symptoms often moderate, but the suppression of urinary secretion 
persists, due to the change produced in the kidneys by the drug. 
This should be prevented, if possible, not only by the free ingestion 
of water by the mouth but also by the rectal drip (see Peritonitis, 
Part IV), containing acetate of potassium or citrate of potassium, 
1 dram to the pint. This drip should be persisted in day and 
night unless anasarca develops, when it should be stopped. As a 
considerable amount of the drug is eliminated by the bowel a full 
colonic lavage should be done twice a day to aid in getting rid of 
the poison. Death may be delayed in these cases for many days. 
Recovery rarely occurs unless the stomach is rid of the poison before 
it can be absorbed in any quantity. 

Not only does the bichloride of mercury produce symptoms of 
acute poisoning when taken in large doses, but it is also capable of 
causing a form of subacute poisoning in those patients who have it 
applied too freely as an antiseptic wash or lotion. Particularly are 
these symptoms developed after intra-uterine or vaginal irrigations 
with bichloride solutions. The symptoms are abdominal pain, diar- 
rhea with tenesmus, and finally sanguinolent discharges. There is 
also scanty urination or the activity of the kidneys may be entirely 
suppressed. In some cases death comes rapidly, but sometimes 
even the symptoms themselves do not develop for several hours after 
the drug is employed. 

The bichloride of mercury is an exceedingly useful preparation of 
mercury for hypodermic injection in fulminant syphilis, and is better 
than calomel for this purpose. About J grain (0.01) may be injected 
deeply and gently into the cellular tissues every two or three days. 
When the injections are made the greatest possible cleanliness should 
be obtained. The syringe barrel should be of glass, the needle and 



MERCURY 373 

syringe should be aseptic, and the hands of the operator well disin- 
fected. The best place for the injection is in the gluteal region or 
between the shoulder-blades. (See Salicylate of Mercury.) 

The intraspinal injection of mercurialized serum has been practised 
with sufficiently good results in cerebrospinal syphilis to justify its 
being mentioned. It would seem that these injections are prone to 
produce more irritation than intraspinal injections of salvarsanized 
serum, and, like such injections, may induce a crisis in ataxia. The 
advantages of the method are that a preliminary intravenous injec- 
tion is not required, and a large amount of serum may be made up 
at one time and kept under strict antisepsis for several weeks. The 
first dose should be small. In ataxia it would appear that the dose 
should be at longer intervals than in other types of cerebrospinal 
syphilis. In the latter the treatments may be as frequent as once or 
twice a week for three weeks. Mercurialized serum is not as effica- 
cious as salvarsanized serum, but may prove a useful substitute, 
although doubt as to the efficiency of intraspinal injections in cere- 
brospinal syphilis seems to be increasing. The following method by 
Haller of preparing mercurialized serum is given. 

In the preparation of mercurialized serum, blood is withdrawn from 
a vein and allowed to clot. The expressed serum is centrifuged in 
order to free it from cells. The serum is then pipetted into glass 
tubes in S cc amounts, and to each tube is added 0.001 gram of 
mercuric chloride in a 0.1 per cent, aqueous solution. The fluid is 
agitated for a few moments in order to insure a thorough mixing. 
The white ring of precipitated albuminate of mercury quickly redis- 
solves in the excess of serum, giving a perfectly clear solution. The 
tubes are plugged and the serum inactivated for thirty minutes at 
56° C. They are then stored away on ice until needed, when they 
are warmed to body temperature and the serum is administered. 

The amount of serum used has seemed to be of relatively little 
importance, although excessive amounts probably add to the imme- 
diate reaction. From 6 to 8 cc has been the amount used in most 
of the doses given in spinal syphilis, for the reason that about that 
amount of spinal fluid is usually withdrawn for cell count, globulin 
and Wassermann tests. The dose of mercuric chloride has been 
varied from 0.0005 to 0.002 gram. The degree of immediate reac- 
tion is not perceptibly changed by increasing the amount to 0.001 
gram, but an increase above this figure has seemed to add materially 
to the discomfort of the patient. The length of time during which 
the serum was heated to 56° C. has been varied from twenty minutes 
to two hours without apparently affecting the degree of reaction. 
The age of serum does not perceptibly add to its irritating properties. 
Several doses kept on ice for eight weeks and more were followed by 
less disturbance than many which were administered within twenty- 
four hours after preparation. 



374 DRUGS 

Mercury bichloride, aside from its antiseptic use (see Antiseptics) , 
is of some value when given internally, not only in syphilis, but to 
aid in combating the pathological lesions induced by that infection, 
as arterio-capillary fibrosis and chronic contracted kidney. In tonsillitis, 
where the inflammation is severe, it is often used early with great 
service. (See also Mercury Biniodide.) 

In small amounts— that is, in ^ to -^ grain (0.001-0.0015) three 
times a day— the bichloride is one of the best remedies for the treat- 
ment of anemia depending upon a deficient number of blood cells. 
If the anemia is syphilitic in origin, it is, of course, peculiarly useful. 
Bichloride of mercury is of value in minute doses of ^-J-^ grain (0.0001) 
for the ill-smelling green stools of summer diarrheas in adults and 
children, and it has been recommended that a solution be made 
of | grain (0.03) in 5 ounces (150.0) of water, and a teaspoonful 
given every hour until relief is obtained. The water used in making 
the solution should be distilled, and it may be well to add to it a 
little tartaric acid to prevent precipitation of the bichloride by 
organic matter which may have gotten into the water. This treat- 
ment is particularly useful in mucous diarrhea in which blood and 
mucus are thoroughly mixed. Patients in the dispensaries often 
speak of these passages as containing "corruption," and others 
think they consist of "lumps of flesh," owing to the masses of blood 
and mucus. Whether the disease be acute or chronic, the bichloride, 
used in the way just described, will be found of service. In dysentery 
and the diarrhea of adults the same treatment may be resorted to, 
using 2 teaspoonfuls of the solution instead of 1. It is hardly neces- 
sary to add that the greatest care must be bestowed upon the diet 
and clothing. The author has treated a child suffering from per- 
sistent diarrhea for months with varying success, only to succeed 
when, it being found that the abdomen was exposed to the air, the 
mother was forced to apply and keep on the child a flannel binder. 

In some cases in which an obstinate syphiloderm is present \ ounce 
(16.0) of corrosive sublimate and 1 ounce (30.0) of chloride of ammo- 
nium may be added to a warm bath, which should be taken every 
few days. One-half a grain (0.3) of the bichloride of mercury in 6 
ounces (180.0) of water is said to be efficient as an injection in gleet, 
if used every three or four hours. (See Gonorrhea.) 

In all parasitic affections of the skin a solution of 2 grains (0.12) 
of bichloride to the ounce (30.0) of water may be sopped on the part 
three times a day. A solution of perchloride of mercury (Liquor 
Hydrargyri Perchloridi) 1 to 1000 is official in the B. P. It is given 
in the dose of J to 1 fluidram (2.0-4.0). 

Tablets for surgical use are now official under the name of Toxi- 
tabelke Hydrargyri Chloridi Corrosivi, U. S. 

(For the antiseptic uses of the bichloride of mercury see Antiseptics 
and Disinfectants.) 



MERCURY 375 



Biniodide of Mercury. 

Red mercuric iodide (Hydrargyri Iodidum Rubrum, U. S. and B. P.) 
is a bright red powder, possessing irritant powers equal to or greater 
than those of the bichloride, and causing symptoms, when taken in 
overdose, closely resembling those produced by the latter drug. 
Owing to the formation of the salt, it is thought to be particularly 
useful in the later stages of syphilis. The dose is ^ to y^ grain 
(0.002-0.004). It may also be given intramuscularly dissolved in 
water or oil with anesthdne to prevent pain. The best way to employ 
it is in ampoules. If the oil is used absorption is slower than if 
water solutions are employed. The dose so used is J grain (0.01). 
(See Syphilis.) An ointment (Unguentum Hydrargyri Jodidi Rubri, 
B. P.) is useful as an application in goiter and obstinate skin diseases. 
In the dose of ^fo" grain every hour for 4 or 6 doses this drug is a 
most useful remedy to abort acute tonsillitis. 

At one time it was thought that biniodide of mercury was a better 
antiseptic than the bichloride, but recent researches have proved 
that this is not a fact. 

Black Wash. 

Black wash (Lotio Hydrargyri Nigra, B. P.) is made by adding 1 
dram of calomel to a pint (4.0:480 cc) of lime-water. It is used 
as a stimulant application for washing syphilitic sores and wounds 
in various forms of eczema. 

Blue Mass. 

Blue mass (Massa Hydrargyri, U. S.; Pilula Hydrargyri, B. P.) 
is made by rubbing up metallic mercury with liquorice and other 
excipients, and is often called blue pill. Each grain of the mass 
contains J grain (0.02) of mercury, and it may be given in the dose 
of from \ to 20 grains (0.03-1.3) for the. same laxative purposes for 
which calomel is used. Blue mass is rarely employed to produce 
systemic effects. 

Calomel. 

Calomel (Hydrargyri Chloridum Mite, U. S.; Hydrargyri Sub- 
chloridum, B. P.), or mild mercurous chloride, is an insoluble salt 
which is, nevertheless,, freely absorbed. 

Calomel when used as a laxative purge should be given in the 
dose of | to | grain (0.01-0.03) every half-hour or every fifteen 
minutes until 1 or 2 grains (0.06-0.12) are taken, as it will often 
act as efficiently in this way as if 10 grains (0.6) are given at one 
dose, and there is no danger of producing ptyalism. The reason that 
small doses are as efficient as large ones lies in the fact that only the 
calomel which is changed into the gray oxide is active, and, as the 
amount of alkaline juice in the intestine is small, only a minor part 



376 DRUGS 

of a large dose of calomel acts, the major portion escaping unchanged. 
This is the reason that bicarbonate of sodium is added to calomel 
powders, to aid the intestinal juice in the reduction of the salt. 
While this statement as to small dose is true of the use of calomel in 
temperate climates, it does not hold good in hot climates, where 
much larger doses, amounting to 10 (0.6) or even 20 grains (1.3 
are often given to affect the flow of bile, the hepatic gland being 
made torpid by heat. If purgation does not occur after a full dose 
of calomel, a saline purge must be given at the end of the twenty- 
four hours, and this must always be used if large doses of the mer- 
curial are employed, to avoid possible mercurialization. 

Mercury in the form of calomel has been used hypodermically in 
the treatment of syphilis. It is best used in the dose of 1 to 3 grains 
(0.05-0.15) suspended in goose oil put up in sterile ampoules. It 
should be injected deeply into the tissues, not immediately under- 
neath the skin, the greatest cleanliness being necessary to avoid 
abscesses. The best place for these injections is above the fold of the 
buttocks, but sloughing, tetanus, and even gangrene have followed 
its employment in this way. (See also Salicylate of Mercury, 
Bichloride of Mercury, and Gray Oil.) 

Calomel has been used by inunction in syphilis, put up in the form 
of "calomelettes" containing in each 100 grains (6.6) of cocoa butter, 
50 grains (3.3) of calomel. These have the advantage over Blue 
Ointment of not staining the skin or clothing, but calomel ointment 
is not equally effective. 

In dysentery of the acute form calomel and ipecac are valuable 
remedies. (See Dysentery and Ipecac.) The calomel should be given 
in small doses, repeated every hour or half-hour until a favorable 
change in the number and character of the stools appears. Calomel 
is not to be used if great asthenia complicates the disease. 

In children who seem constantly "under the weather" and never 
quite well, who have flatulence, fetid breath, and ill-smelling, pasty 
stools, calomel often gives great relief in the dose of grain 2V (0.003) 
every half-hour until four doses are taken, this treatment being 
pursued every fourth or fifth morning. 

In slight jaundice due to cold and hepatic congestion £ grain 
(0.01) of calomel every half-hour until 1 grain (0.06) is taken will 
often bring relief. It is contraindicated in obstructive jaundice. 

Calomel is generally prescribed in conjunction with sugar of milk, 
white sugar, or bicarbonate of sodium, which are added to increase 
the bulk and wieldiness of the powder, and, in the case of the first 
ingredient, to increase its activity by finely grinding it. Owing to 
its lack of taste, calomel is often placed on the tongue in children, 
and for this class of patients white sugar is to be used in small quan- 
tity as a vehicle, as the other vehicles are less agreeable. The most 
pleasant form of administration is by means of triturates. These 
should not be compressed. 



MERCURY 377 

It is important to remember that calomel when used as an anti- 
syphilitic produces salivation much earlier than the other mercurials. 

Sometimes calomel is of value when dusted into the eye in cases 
of 'phlyctenular conjunctivitis which are strumous. This practice 
must not be resorted to if iodine or iodides are being taken internally, 
as the iodine is eliminated by the tears and forms a compound which 
burns the conjunctiva. 

A very important use of calomel and one which has been brought 
forward as new, but which is really many years old, is its employ- 
ment in dropsy as a diuretic, either alone or combined with squills 
or digitalis, or with opium to prevent purging. The dose is small, 
about 1 grain (0.06) thrice a day, and if a diuretic influence does 
not assert itself in forty-eight hours it should not be continued. 
How calomel acts to produce the increased urinary flow under these 
circumstances is not known. Some suppose that it aids the absorp- 
tion of liquid from dropsical tissues, and so increases urinary secre- 
tion; others think that it stimulates the renal epithelium to greater 
activity. The latter view seems the least probable of the two, but 
neither theory has been proved correct, although experimentation 
supports the view first named. The full urinary effect of the drug is 
not felt till the second or third day of its use, and speedily passes 
away, particularly as purging is often induced very early. Still 
another use of calomel is in typhoid fever, in which disease it has 
been highly recommended in small repeated doses, particularly if 
constipation is present. In the opinion of the author this is dis- 
advantageous as a routine measure and entirely uncalled for, although 
in the very early stages of the disease, when the bowels are confined 
and the tongue coated, a dose of 1 grain (0.06) in fourths with a little 
bicarbonate of sodium is useful followed by a Seidlitz Powder. 

Sydney Ringer called attention to the fact that in constipation 
or in " 'biliousness" podophyllin does more good than calomel, pro- 
vided that the stools are dark in color, whereas if the same symp- 
toms are present, but the stools light and clayey in color, calomel is 
more efficient. The author has proved the correctness of this 
assertion so frequently that he is convinced of its truth. 

Calomel has been recommended in the condition of anorexia and 
depression following acute diseases, and when the tongue is covered 
by a thick yellow coat it is the remedy for the gastro-intestinal torpor 
always present. While purgative doses of calomel certainly are of 
value, the use of freshly prepared nitromuriatic acid is, however, 
highly preferable to the mercurial salt in many such instances. Both 
of these drugs should not be given simultaneously, because they are 
incompatible. 

Calomel is often given in small doses to "settle the stomach." 
Sometimes it will act in this way, but in other cases it will seem to 
increase the nausea and bring on vomiting. This is true of both 
adults and children, and it is impossible to tell beforehand which will 



378 DRUGS 

occur. Ringer asserts that in a peculiar form of vomiting occurring 
in very young children, which comes on immediately after the food 
is swallowed the rejection of milk being forcible, and perhaps so 
sudden that it is not even curdled, and which is not accompanied by 
much straining, calomel will often give relief when all other remedies 
fail. It should not be resorted to until some evidences of wasting 
occur, as this action of the stomach in many children only rids that 
organ of that part of the milk which is in excess, and is a purely 
physiological regurgitation. The calomel may be given in the dose 
of T V grain (0.005) every hour, or, if preferred, gray powder in the 
dose of | grain (0.02) every hour for three doses, is equally efficient 
in these cases. If it fails to give relief hypertrophic stenosis of the 
pylorus is perhaps the cause. 

Calomel in a fine powder will often remove syphilitic condylomata 
if dusted over them for some time, and an ointment made of 1 dram 
(4.0) of calomel to 1 ounce (30.0) of lard is very useful in pruritus ani. 

It has been proved that an ointment of calomel if used on the penis 
immediately after sexual intercourse acts as an efficient prophylactic 
against syphilis. The strength used is 4 drams (15.0) to the ounce 
(30.0). 

The B. P. contains a pill mass of calomel, called Pilula Hydrargyri 
Subchloridi Composita, which contains antimony, guaiac resin, and 
castor oil. Its dose is 2 to 8 grains (0.12-0.5). 

Calomel ointment (Unguentum Hydrargyri Subchloridi, B. P.) is 
often useful in the treatment of small patches of eczema, or the 
following prescription may be given: 

1$ — Hydrargyri chloridi mitis gr. xl (2.6) 

Magnesii carbonatis gr. xl (2.6) 

Unguenti aquae rosse . . . . 5j (30.0). — M. 

Gray Oil. 

Gray oil (Oleum Cinereum) is prepared as follows: 2 drams (8.0) 
of lanolin are rubbed up with sufficient chloroform to emulsify it. 
The rubbing process is continued until most of the chloroform is 
evaporated, and while the mixture is still in a fluid state metallic 
mercury, in double the amount of lanolin, 4 drams (16.0), is added 
and the trituration continued. By this means an ointment of mer- 
cury is left which equals 2 parts of mercury and 1 of lanolin. This 
is sometimes called strong gray ointment. For hypodermic injec- 
tion 3 parts of this gray ointment are added to 1 part of olive oil, 
or it may be still further diluted by adding olive oil in the proportion 
of half-and-half. Of this mixture 1 to 2 minims (0.05-0.1) may be 
injected every second or third day. 

By some practitioners this preparation is considered much better 
than any other for hypodermic use in syphilis. 



MERCURY 379 

Mercury with Chalk. 

Mercury with chalk {Hydrargyrum cum Creta, U. S. and B. P.), 
or gray powder, is slightly purgative, but is chiefly employed in the 
treatment of infantile syphilis, as it will not freely purge. It is com- 
posed of 38 parts of mercury, 10 parts of honey, and 57 parts of pre- 
pared chalk. The dose is 1 to 10 grains (0.06-0.6). Children suffer- 
ing from syphilitic marasmus seem fairly to fatten on it. This 
preparation is also of service in the syphilis of adults, and may be 
employed whenever the laxative effect of mercury is not desired. 

In the treatment of infantile diarrhea with watery, colorless stools 
containing undigested food gray powder in small doses is often very 
useful. 

Mercury Ointment. 

The ointment of mercury, mercurial ointment (Unguentum Hydrar- 
gyri, U. S. and B. P.), is made by rubbing up metallic mercury and 
oleate of mercury with suet and lard until the mercury is extinguished, 
or, in other words, until the globules of mercury cannot be seen with a 
magnifying power of ten diameters. Diluted ointment of mercury 
(Unguentum Hydrargyri Dilutum, U. S.), "Blue Ointment," con- 
taining 67 parts of mercurial ointment in 100 of petrolatum is also 
official. The first of these is the preferable preparation of the two. 

An efficient method of using mercury by inunction is to employ 
so-called " Mercurettes" which consist of minutely subdivided metal- 
lic mercury in cocoa-butter compressed into small blocks, each 
containing 30 grains (2.0) of mercury. (See Calomelettes under 
Calomel.) 

The ointment of mercury is used externally in skin affections and 
for the purpose of influencing the general system. In syphilis the 
ointment in small amounts should be thoroughly rubbed into the skin 
in various parts of the body— one evening in the left groin, the next 
evening in the right groin, the following evening below the left axilla, 
and the fourth evening below the right axilla, beginning on the fifth 
evening in the left groin once more. This avoids local irritation of 
the skin by too frequent applications, places the drug on spots 
where it is readily absorbed, and rapidly influences the system of the 
patient. In infantile syphilis this method may be employed, or a 
flannel binder covered with the ointment may be placed about the 
belly. The clothes should not be changed too frequently, as their 
saturation aids in producing the effects. The wearing of an under- 
shirt saturated with the ointment is a valuable, though somewhat 
dirty, method of producing mercurialization. 

When the use of mercurial ointment in the usual areas is inadvis- 
able, because its presence is shown to others, it may be applied to the 
sole of each foot on alternate days, the patient wearing dark stockings. 

Under the name of Oleate of Mercury (Oleatum Hydrargyri, U. S. 



380 DRUGS 

and B. P.) a very efficient and more agreeable application than the 
ointment is used in its place or still further diluted with lard, when 
it becomes the Unguentum Hydrargyri Oleatis, B. P. It is made 
from the yellow oxide of mercury. (See Oxides of Mercury.) 

For pediculus pubis, or in any case where parasites, such as the 
flea or louse, infest the region of the genitals or any spot covered by 
a hairy growth, mercurial ointment may be used as a remedy, owing 
to its lethal influence over these pests. Care should be taken that 
it does not cause salivation of the patient, and it must not be allowed 
to remain on the parts, but be wiped off in the course of an hour or 
two or less. " We may here say that if it is once understood that all 
insects, including lice, are destroyed quickly by the application of 
any fixed or volatile oil, physicians will see there is no necessity of 
employing remedies of a noxious character to the patient. The fat of 
mercurial ointment is probably more active than the mercury itself." 
(Leidy.) 

Linimentum Hydrargyri, B. P., and Emplastrum Hydrargyri, B. P. 
are used for the same purposes as is the ointment of mercury. The 
plaster is made with olive oil, resin, and lead plaster instead of 
ordinary suet or lard. 

Nitrate of Mercury. 

The solution of mercuric nitrate (Liquor Hydrargyri Nitratis 
Acidus, B. P.), acid nitrate of mercury, is an exceedingly active, 
penetrating caustic, so rapid in its effects that it seems to eat into 
the tissues. It may be employed for the removal of epitheliomata 
and large warts, and should be applied by means of a glass rod. This 
treatment may also be resorted to with advantage in lupus until the 
surface of the growth is level with the skin. The surrounding parts 
should be protected by lard or oil. As this treatment is very painful, 
the spot may be first cocainized and afterward covered with flexible 
collodion. 

Citrine ointment (Unguentum Hydrargyri Nitratis, U. S. and 
B. P.) is used as a stimulating application in cases of chronic skin 
diseases of the scalp and trunk. It is too strong for ordinary use, 
and should be diluted one-half or less with lard according to the 
stimulating effect required; the dilute ointment is official in the 
B. P. as Unguentum Hydrargyri Nitratis Dilutum. 

Oxides of -Mercury. 

The yellow and the red mercuric oxides (Hydrargyri Oxidum 
Flavum, U. S. and B. P., and Hydrargyri Oxidum Rubrum, U. S. 
and B. P.), red precipitate, are used largely as a dressing for syph- 
ilitic sores when diluted about one-half with chalk or other powder. 
If used pure, they are somewhat caustic. From the yellow oxide is 
made the oleate of mercury (Oleatum Hydrargyri, U. S., Hydrargyrum 



MERCURY 381 

Oleatum, B. P.) which is used for the same purpose as ordinary 
mercurial ointment. 

In intestinal and gastric indigestion, with foul belching and very 
ill-smelling stools which are due to intestinal fermentation, the yellow 
oxide is sometimes given in the dose of -$-$ to -tfo grain (0.001-0.0012) 
in a triturate. 

Red precipitate ointment (Unguentum Hydrargyri Oxidi Rubri, 
B. P.) and the ointment of the yellow oxide (Unguentum Hydrargyri 
Oxidi Flam, U. S. and B. P.) are largely used, diluted one-half with 
lard, for chronic scaly skin affections, in obstinate conjunctivitis, and 
in granular lids and styes. (See Styes.) They should always be 
freshly prepared. 

Protiodide of Mercury. 

Yellow mercurous iodide (Hydrargyri Iodidum Flavum, U. S.) is 
much more mild than the biniodide, and is given for exactly the 
same purposes. It is often useful in chronic Bright's disease. It is 
to be remembered as the best mercurial preparation for ordinary 
cases of secondary syphilis. (See Syphilis, Part IV.) It should be 
given in ascending doses. The beginning dose is \ to J grain 
(0.01-0.015) three times a day. 

Salicylate of Mercury. 

Hydrargyri Salicylas, U. S., is a drug which has come into quite 
general use since the introduction of the hypodermic method of 
administering mercury in syphilis. It may be suspended in paraffin 
oil (liquid albolene) in the proportion of 1 grain (0.05) of the salicy- 
late of mercury to 10 minims (0.6) of the oil, and before it is used 
the bottle must be well shaken in order that the insoluble mercury 
may not remain at the bottom. 

Salicylate of mercury is also placed on the market in sterile am- 
poules, containing 1 grain (0.06) or more. The drug is suspended in 
a fatty base which in some instances must be heated in order to 
liquefy it. The best ampoules to use are those in which goose oil 
is employed, as it remains in fluid form at ordinary temperature 
and so does not need heating. 

Before giving the injection the buttock should be painted with 
tincture of iodine. The needle should be large and long and well 
oiled before it is used. A 20-gauge needle is the best needle to use 
to carry the heavy fluid. If an oily solution is used the mercurial 
does not attack the metal. The buttock having been sterilized, the 
injection should be given while the patient is in the standing posi- 
tion at the sites shown in Fig. 55. This method has a great advan- 
tage in point of convenience and pain, as compared to the bichloride 
of mercury which often causes soreness and induration. It is of 
great importance that the needle and syringe should be thoroughly 
cleansed after each injection, as the insoluble drug readily clogs the 



382 



DRUGS 



instrument. One grain should be injected deeply into the muscles 
of the gluteal region every fourth day, and this may be increased to 
every second day if no evidences of the systemic action of the drug 
appear, but these injections should not be continued too long, as 
absorption is uncertain as to speed and ptyalism may be induced. 




Fig. 55. — Sites for the mercurial injections. (Gottheil.) 



Yellow Sulphate of Mercury. 

Hydrargyri Subsulphas Flavus has been used under the name of 
turpeth mineral as an irritant in chronic ophthalmia and also as a 
prompt emetic in croup. It is a quick and certain emetic, and it is 
claimed, does not produce depression, but the writer would recom- 
mend great care in its use. The dose for a two-year-old child is 
2 to 5 grains (0.12-0.3), repeated in fifteen minutes if necessary. 

If as much as 5 grains (0.3) has been given, and emesis does not 
follow, other emetics or the stomach-pump must be used to prevent 
gastro-intestinal irritation. 

Yellow Wash. 

Yellow wash (Lotio Hydrargyri Flam, B. P.) is made by adding 
30 grains (2.0) of corrosive sublimate to a pint (480 cc) of lime- 
water. It is used for the same purposes as the black wash already 
mentioned, but is much more stimulating. 



METHYL BLUE 383 

Licompatibles. — Bichloride of mercury should never be given with 
any other substance except iodide of potassium and chloride of ammo- 
nium, as it is incompatible with almost every other drug. With the 
iodide of potassium it may be used because the precipitate formed is 
at once redissolved and the resulting mixture is highly alterative. 

Calomel should never be given with iodides or bromides, and 
hydrochloric acid may convert it into the bichloride if the acid is 
present in any amount. It is also incompatible with antipyrine. 



METHYL BLUE. 

Methyl blue, or methyl violet, is an aniline dye often sold under 
the name of pyoktanin. When used medicinally it must be per- 
fectly pure and deprived of its usual contaminating matter, arsenic, 
which if present causes local irritation of the part to which it is 
applied. Pyoktanin was introduced to professional notice under this 
name by Stilling as an antiseptic, but careful study has proved it to 
possess but feeble power over the growth of germs. In all conditions 
of the eye in which antiseptic lotions are indicated pyoktanin has 
been stated to be of value, but elsewhere in surgery it is practically 
useless as an antiseptic. Even in the eye it possesses, according to 
de Schweinitz, a limited range of usefulness, being no better than 
the older antiseptics, except in diseases of the lacrimal apparatus. 
The fact that pyoktanin stains everything it touches is a great dis- 
advantage in its use. It may be tried in blepharitis, eczema of the 
eyelids, conjunctivitis, both simple and phlyctenular, and in the 
treatment of corneal ulcer. When so employed, it should be applied 
in the strength of 1 to 1000 of water. 

It should be remembered that any pure aniline dye may be used 
in place of pyoktanin. Thus some physicians have used yellow 
pyoktanin or auranine. 

Methyl blue and similar aniline substances have been largely 
employed by some physicians in the treatment of malignant neo- 
plasms. The solution (1 to 500 of water) should be filtered through 
hot asbestos to render it sterile, and every antiseptic precaution 
carefully observed in giving the injection. The dose is J to 3 drams 
(2.0-12.0) of this solution every other day or every third day, and the 
injection is to be given either into the growth itself if it is large, or 
just at its side, in the healthy tissues, if it is small. Too much should 
not be injected into one spot lest it cause a slough. This treatment 
does not cure the disease. It relieves pain and so quiets the patient, 
and in rare cases checks the growth of the tumor. If the growth 
sloughs, complete antiseptic dressing is necessary. An antiseptic 
pyoktanin-gauze dressing should always be used while the treatment 
is under way. 



384 DRUGS 

METHYL CHLORIDE. 

Methyl chloride is a colorless gas, easily liquefied under pressure, 
with an odor resembling that of ether and chloroform, and is used to 
produce local anesthesia, which it does by absorbing a large amount 
of heat on passing from the liquid to the volatile state as it strikes 
the skin. It is usually kept in a small flask which has its open end 
covered by a metal cap. When this cap is removed the heat of the 
hand volatilizes the drug, which is then forced out of the flask in a 
fine spray. The nozzle should be held ten to twelve inches from the 
part to be frozen. Before the spray is used the skin of the part to be 
anesthetized should be washed with soap and ether to remove all 
fatty substances. 

Under these circumstances the skin becomes pale in a few seconds, 
and afterward white and parchment-like in appearance. Local anes- 
thesia is now complete, and minor surgical operations, such as open- 
ing boils or abscesses, can be performed without pain. The spray 
should not be continued more than two to four minutes, as local 
death of the tissues may result. Advantages of the spray of methyl 
over that of ether are its slight inflammability and rapidity of action. 
Methyl chloride should not be confounded with methylene chloride. 
The first is monochlormethane, the second dichlorme thane. 

METHYLENE BLUE. 

Methylene blue (Methylthionince Chloridum, U. S.) is to be dis- 
tinctly separated in the mind of the student from methyl blue, which 
is practically what is known by the trade name of "pyoktanin." 
The latter ought not to be used internally. Methylene blue occurs 
as a dark-green, crystalline powder, or in the form of prismatic crys- 
tals having a bronze-like luster. It is readily soluble in water and 
somewhat less readily in alcohol, the solutions having a deep blue 
color. Methylene blue can be distinguished from methyl blue by 
this test: With sodium hydroxide methyl blue gives a purplish red, 
while methylene blue turns a deep violet. Also, when a solution of 
the former is made in a test-tube the meniscus is blue, whereas with 
methylene blue it is greenish. 

Methylene blue has been employed in the treatment of malignant 
growths and in malarial fevers with asserted success, although its 
successful use in the first group of cases is decidedly problematical. 
When used in the treatment of sarcoma and cancer, from J to 2 grains 
(0.03-0.12) in watery solution are injected daily or on alternate days 
directly into the growth. The neoplasm, it is said, ceases to grow, 
shrinks, and comes away, leaving a fairly healthy sloughing surface. 

This treatment is so uncertain that it should only be tried in 
inoperable cases, and in this class of patients its local use often seems 
to relieve the pain and check the fetor. 



METHYLENE CHLORIDE . 385 

In malarial fever of the intermittent type methylene blue seems 
to possess distinct curative powers. It is not so powerful as quinine 
by any means, but has its chief sphere of usefulness in patients who 
cannot take quinine or where quinine has been tried unsuccessfully. 
This antimalarial influence is due to its destruction of the Plas- 
modium malaria", but its administration must begin from seven to ten 
hours before the expected intermittent paroxysm and be continued 
after the attacks have ceased and for some little time after the 
physician fails to find the microorganisms in the blood, as relapses 
are common. Particularly good results seem to follow the use of 
methylene blue in children suffering from malaria. Untoward symp- 
toms from its use are not common, but when they do occur consist 
in slight vertigo, nausea, and some strangury, which latter symptom 
can be prevented to a great extent if powdered nutmeg (equal 
parts) is given simultaneously. The urine is always blue from the 
elimination of the drug through the kidneys. 

Recently, Levy has employed methylene blue in the dose of from 
1 to 2 grains (0.06-0.12) four times a day in the treatment of migraine. 
It is to be given in capsule with kola. He states that as much as 15 
grains (1.0) may be given in a day with safety. 

Methylene blue has been highly recommended by Horwitz in the 
treatment of the earlier stages of gonorrhea, as it shortens the course 
of the disease. He suggests the following formula: 

Methylene blue 2 grains (0.12) 

Oil of sandalwood 3 " (0.2) 

Oleo-resin of copaiba 3 " (0.2) 

Oil of cinnamon 1 minim (0.05) 

To be made in one capsule, three of which are to be taken each day. 

Injected into a muscle in the dose of 1 grain in 10 minims of water, 
methylene blue is used to test the activity of the eliminative function 
of the kidneys. In health it should appear in the urine in fifteen to 
thirty minutes, and persist for thirty-six hours. 

When the kidneys are healthy the same test may be made to deter- 
mine whether an effusion in the pleural cavity or peritoneum is capable 
of being absorbed as a result of purgation. From 1 to 3 grains in 
solution are injected into the fluid in the chest, or abdomen, and 
a purge given. If the blue does not appear in the urine, this fact 
shows that absorption from the pleura or peritoneum has not occurred, 
because the lymphatics are blocked by inflammatory exudate. 

The ordinary dose in the treatment of malaria is 2 to 4 grains (0.12- 
0.25) every four hours to adults, or 1 to 2 grains (0.06-0.12) to children 
of five years, preferably given in capsule. 

METHYLENE CHLORIDE. 

Methylene chloride is made from chloroform or by the action of 
chlorine on marsh-gas, and is a colorless liquid resembling chloroform 

25 



386 DRUGS 

in odor. It is readily decomposed by light, which change may be 
hindered by the addition of a little absolute alcohol. 

Therapeutics.— Methylene chloride is employed as an anesthetic in 
a manner like chloroform, and was introduced as a substitute for 
that drug, but is of doubtful safety and is little used. It has been 
used as a spray for the production of local anesthesia. As stated 
under Methyl Chloride, it is not to be confounded with that drug. 

In England, under the name of "methylene chloride" or "methyl- 
ene," a mixture of ethyl chloride and methylene chloride has been 
widely employed by inhalation as an anesthetic. This preparation 
is, of course, to be distinguished from true methylene chloride. The 
amount of this mixture used to produce anesthesia is 1 to 2 drams 
(4.0-8.0) for minor and 3 to 6 drams (12.0-24.0) for major operations. 
The term "methylene chloride" has also been applied to a mixture 
of chloroform and methyl chloride. 

MUSK. 

Musk (Moschus, U. S.) is the dried secretion obtained from the 
preputial follicles of Moschus moschiferus, or musk deer of Thibet, 
and is a substance possessing remarkably penetrating powers, so far 
as odor is concerned. Very little of the musk for sale in the shops 
is pure, and most of it is not musk at all. Its price varies greatly, 
but if sold for less than twenty-five cents a grain it is probably 
worthless or impure. 

Therapeutics.— For some unknown reason musk acts as a diffusible 
stimulant and supports the system. It is also an antispasmodic and 
nervous sedative. In all low fevers where the strength of the patient 
is fast ebbing and the nervous symptoms are those of the most 
advanced depression, rectal injections of musk in starch-water may 
be employed. The dose should be 5 to 10 grains (0.3-0.6). This 
drug is of value where either nervous excitement or nervous collapse 
is present, but is not to be employed until it is absolutely needed to 
carry the patient past a crisis. If frequently employed, it loses its 
power and the expense is a needless one. 

Musk is one of the best remedies in obstinate hiccough. 

The dose of the tincture ( Tinctura Moschi, U. S.) is 40 minims to 
1 dram (2.0-4.0), and of musk itself 5 to 10 grains (0.3-0.6). 

MUSTARD. 

Mustard is official in the form of Sinapis alba, U. S., or white 
mustard, derived from the seeds of Sinapis alba, and Sinapis nigra, 
U. S., or black mustard, derived from the seeds of Brassica nigra. 
An irritant oil (Oleum Sinapis Volatile, U. S. and B. P.) is formed by 
ferment action when black mustard comes in contact with water. 
An albuminoid ferment, myrosin, acts in the presence of H 2 on 
the glucoside sinigrin, forming the oil and dextrose. 



MUSTARD 387 

Therapeutics.— Mustard is often used in the form of mustard flour 
as an emetic when stirred in water in the proportion of 2 tablespoon- 
fuls to a glass of water. It is also employed as a counterirritant 
and as a condiment. If given in excessive dose, it will cause violent 
gastritis, and chronic gastritis is often set up by its constant use in 
excess. Its internal use is contraindicated during the existence of 
acute gastritis and all states of gastro-intestinal irritation. 

When used as a counterirritant mustard is applied to relieve the 
pain of colic due to flatulence and acute inflammation of the abdominal 
and thoracic viscera, that due to muscular rheumatism, inflamed joints, 
and neuralgia, and it may be applied at the nape of the neck in cases 
of headache and cerebral congestion. When applied to the skin of an 
ordinary individual, it will produce a severe burn if left on more 
than a few minutes, and it should be mixed with wheat flour in the 
proportion of one to four when used upon tender skins. Children 
generally will not tolerate more than one-sixth mustard. The 
plaster should be made by mixing mustard flour and wheat flour 
together and then moistening the mixed flours with warm water or 
warm vinegar, or a little brandy may be used. 

In the capillary bronchitis of young children and in the early stages 
of the eruptive fevers, when there is torpor and a poorly developed 
rash, mustard oil may be used in conjunction with the wet-pack in 
the following manner: It is particularly indicated when there is 
paralysis of the peripheral capillaries and mottling of the skin. A 
piece of flannel large enough to surround the child from its neck to 
its feet is wet with a mixture made as follows: To 8 ounces (250 
cc) of water at room temperature add the same amount of alcohol. 
To this alcohol-water mixture is added 1 to 2 ounces (30.0-60.0) of 
a mixture composed of 1 part of oil of mustard and 49 of pure alcohol. 
After the flannel wet in this manner is wrapped about the child, the 
patient is wrapped again in a dry sheet or light blanket and allowed 
to rest for ten to twenty minutes. When the flannel is taken off, 
the skin is found ruddy with blood and the general state improved. 
The child is now wrapped in a dry flannel or blanket and allowed 
to sleep. This plan cannot be used oftener than once in twenty- 
four hours, because if resorted to too frequently it will irritate the 
skin. 

The scald or burn produced by mustard is peculiar in its slowness 
to heal and in the fact that it is tender and reddened for days. Often 
it produces a permanent stain of the skin. If the burning of the 
mustard becomes excessive, it should be treated by applying a piece 
of lint soaked in lime-water and olive oil, half-and-half, or olive oil 
alone may be used. 

The oil of mustard is very irritant, and almost epispastic in its 
effects. It is sometimes given in the treatment of the atonic stomach 
of drunkards in the dose of J to \ minim (0.015-0.03). Emplastrum 
Sinapis, U. S. and B. P., or mustard-papers, are sometimes called 



388 DRUGS 

sinapisma, and these afford a ready means of applying this counter- 
irritant. They are generally very strong, and one or two layers of 
thin and moistened linen should be placed between the skin and 
the sinapism to prevent too great an action. (See Counter irritation.) 
The compound liniment {Linimentum Sinapis Compositum; Lini- 
mentum Sinapis, B. P.) is composed of the oil of mustard, castor 
oil, extract of mezereum, and alcohol. The mezereum is omitted 
in the British preparation, which is twice as strong in mustard oil 
as that used in the United States. 

MYRRH. 

Myrrh, U. S. and B. P., is a gum-resin obtained from Commiphora 
myrrha, a tree of Arabia. It occurs in dark-colored tears, and con- 
tains an active principle, myrrhin. 

Therapeutics.— Myrrh, in medicinal amount, is a stimulant to the 
circulation and to the uterine and the bronchial mucous membranes. 

In amenorrhea due to functional inactivity or anemia, "iron and 
myrrh" is a standard remedy. (See Iron.) 

The tincture of myrrh, diluted one-half, is useful in ulcerated sore- 
throat as a gargle, and the pure tincture is sometimes applied with a 
small brush or by the end of the finger to spongy or tender gums. 

In leucorrhea depending upon uterine trouble and in chronic cystitis 
myrrh is often of service. Sometimes it enters into expectorant 
mixtures given in the later stages of bronchitis. The dose of the 
tincture {Tinctura Myrrha, U. S. and B. P.) is 10 to 30 minims 
(0.6-2.0), J to 1 fluidram (2.0-4.0), B. P. It also enters into the 
composition of Pilula Aloes et Myrrha, B. P., dose two to five pills, 
and Tinctura Aloes et Myrrha, the dose of which is 1 to 2 fluidrams 
(4.0-8.0). 

NEOARSPHENAMINE. 1 

Neoarsphenamine differs from the older remedy arsphenamine 
(which see) in the following facts : It is not a combination of dioxidi- 
amidoarsenobenzol with hydrochloric acid, but with sodium meth- 
analsulphoxylate. It is very soluble in distilled water, and as it 
has a neutral reaction it does not have to be neutralized by sodium 
hydroxide.. It is less deleterious to the patient, that is, less toxic, 
and therefore can be safely given intravenously in larger doses, 
but gram for gram it is less curative, the relative efficiency being 
0.9 neoarsphenamine to 0.5 arsphenamine. Even with these larger 
doses general experience seems to show that it is not as efficacious 
as the older drug. Locally, it is less irritating. (See Arsphenamine.) 

Salvarsan was called "606," whereas neosalvarsan was called 
"914," as that number represents its position in the series of com- 

1 By using the term neoarsphenamine, the physician gets an American product and 
avoids paying a royalty to a German holder of the word neosalvarsan. 



NEOARSPHEN AMINE 389 

pounds made by Ehrlich. It resembles the older product in the 
following facts : It is readily oxidized, and must be prepared freshly 
for each injection and just before the dose is used. Often it does 
best in advanced syphilis if preceded by a course of mercury. It is 
capable, when given in full doses, of causing chills, fever, and impair- 
ment of heart action, and if the kidneys are inflamed may cause 
urinary suppression. In other words, the indications and contra- 
indications to its use are identical with "606." 

Administration. —The drug, contained in an ampoule, is best dis- 
solved in 20 to 30 cc of normal saline solution made with freshly 
distilled water (see Intravenous Injections for precautions) by gentle 
shaking and given at once. Some clinicians dissolve it in sterile, 
distilled water. Vigorous shaking may result in oxidation. The 
intravenous dose varies from 0.15 to 1.5 gram. The water should 
be warmed before, not after the mixture is made. 

The doses usually increase in size. Thus the first dose for an 
adult is 0.9 gram; the second, 1.2 gram; the third, 1.35 gram; and 
the fourth, 1.5 gram. These doses may be given on every third day, 
or at longer intervals of ten days until a negative Wassermann test 
is secured. Seven days is a common interval. Women usually 
receive from 0.75 to 1.2 gram, children from 0.15 to 0.35 gram, and 
infants 0.05 gram. 

An easy method of administration is to remove the butt end and 
piston of a large glass syringe capable of holding 10 cc, and to 
place the neoarsphenamine in the barrel of the syringe, to which 
is added 4 to 8 cc of sterile normal salt solution. The piston is 
replaced in the upper end of the barrel, the butt end screwed on, and 
by gentle shaking a solution is obtained ready for injection. The 
needle is attached to the syringe by means of a short piece of sterile 
rubber tubing. The arm having become congested by a hanging 
posture and by the use of a bandage or tourniquet, is placed in a 
horizontal position and the needle inserted into the bulging vein. 
A slight withdrawal of the piston draws the blood into the lower 
end of the syringe, proving that the vein has been entered, and 
this having been determined, the injection is slowly performed. If 
the skin has been properly sterilized and the injection has not been 
into the wall of the vein no local trouble arises. The patient should 
rest quietly for some hours after the injection, if possible, and should 
not receive the injection immediately after a meal. 

The intramuscular dose is usually about 0.9 gram dissolved in 
30 cc of sterile water. To avoid pain when it is used intramuscu- 
larly it is best to inject beforehand 2 or 3 cc of a 1 per cent, pro- 
caine solution. 

An even simpler method is to introduce 5 cc of freshly distilled 
water into a glass syringe with its needle in place. Then open the 
ampoule containing the drug in the usual manner and after insert- 
ing the needle into the ampoule inject the water; withdraw the needle. 



390 DRUGS 

Place a finger-tip, covered with a sterile finger-cot, over the opening 
and shake until the drug has formed a perfectly clear solution. Re- 
introduce the needle attached to the syringe and draw up the contents 
of ampoule which is then injected into the vein, it being recalled 
that the use of so strong a solution necessitates a very slow injection 
and that if the needle is not in the vein severe inflammation will 
follow. 

Neoarsphenamine is sometimes given by the rectum in the dose 
of 0.9 gram in 25 to 50 cc of water. 



NEOCINCHOPHEN. 

Neocinchophen, or Tolysin, sometimes called novatophan is para- 
methyphenylcinchoninic acid, ethyl ester and is used for the relief 
of rheumatism and gout. (See Atophan) . The dose is 5 to 15 grains 
(0.3-1.0) three times a day. 



NITRATE OF SILVER. 

Nitrate of silver (Argenti Nitras, U. S. and B. P.) is a heavy crys- 
talline salt of silver readily soluble in its own weight of water. 

It is official as the pure nitrate (Argenti Nitras, U. S. and B. P.) 
and as the sticks or fused rolls (Argenti Nitras Fvsus, U. S.), or 
lunar caustic. The latter are never used in medicine internally, only 
the crystals being employed. Applied to the tissues of the body or 
other substances, nitrate of silver causes a brown and finally a black 
stain, which is due to the formation of an oxide of silver. 

Physiological Action. —Nitrate of silver is one of the few astringent 
substances which are applicable to inflamed mucous membranes, as 
it is, with lead, bismuth, and zinc, one of the few drugs of this class 
which is not irritant as well as astringent. Locally applied, it acts in 
pure form, as a powerful caustic, which is, very superficial in its 
effect, as the drug coagulates the albumin with which it comes in 
contact and thereby forms a coat which protects the tissues beneath. 

The action of the drug upon the circulation, respiration, and similar 
vital functions is only partly known, and has no relation to its employ- 
ment in medicine. It is eliminated from the system very slowly. 

Poisoning.— Almost immediately after the ingestion of a poisonous 
dose of nitrate of silver violent pain in the belly, with vomiting and 
purging, is felt. At the same time evidences of widespread gastro- 
enteritis develop. The abdominal walls are knotted and hard, and 
perhaps scaphoid. The face is anxious and livid and covered with 
a sweat. When vomiting occurs the ejecta are brown or blackish, 
or they may be white and curdy. The lips are at first white, but 
quickly become brown, then black. In some cases the nervous 



NITRATE OF SILVER 391 

symptoms are severe, and convulsions with delirium may occur. 
The convulsions are epileptiform. Death ensues either from gastro- 
enteritis or from centric respiratory failure, accompanied by a profuse 
exudation of liquid mucus into the bronchial tubes. 

The treatment consists in the use of common salt, which is the 
chemical antidote, the employment of opium and oils to allay irrita- 
tion, and in the ingestion of large draughts of milk and of soap and 
water for the purpose of diluting the poison and protecting the 
mucous membranes of the esophagus and stomach from the action 
of the irritant. The bodily heat must be maintained. 

Chronic Poisoning.— This is a form of poisoning very rarely seen. 
The most prominent symptom is the pale slate-blue color of the skin, 
which causes the individual to be livid and death-like in appearance. 

Argyria, as chronic silver poisoning is called, is caused by the con- 
tinued employment of the drug until it is deposited in the tissues. 
It is then found in every part of the body. The first signs of dis- 
coloration can generally be seen in the darkening of the conjunctiva 
over the sclerotic coat of the eye or in a dark line on the inner part 
of the lips. 

The treatment of argyria is not hopeful so far as the color of the 
skin is concerned, but the discoloration may be slightly modified in 
some cases by the prolonged use of iodide of potassium to aid in the 
elimination of the silver. 

Therapeutics.— Internally this salt is used as a cure for gastric ulcer, 
and it is certainly the best drug we possess if combined with extract 
of hyoscyamus or opium and given in pill form. In chronic gastric 
catarrh and gastritis nitrate of silver is very useful when the patient 
is troubled with sour eructations or when vomiting occurs after 
meals. When used in these states, it should be given in £ to \ grain 
(0.1-0.015) doses, half to one hour before each meal, in order that 
the stomach may be exposed to its effects and not be protected by 
food. 

In intestinal ulceration the drug has been highly recommended by 
Pepper, and under these circumstances should be given in hard or 
keratin-coated pills, in order that it may pass through the stomach 
without being chemically changed. In ulceration of the cecum and 
rectum and in acute and chronic dysentery the disease may be attacked 
by rectal or colonic injections of nitrate of silver. If the cecum is 
involved, the solution must be given in large quantity in order to 
reach the part affected; but if the rectum is diseased, the amount 
of liquid injected should not exceed 4 ounces, the bowel in either 
case being washed out beforehand by warm water to rid it of feces. 
Soap and water and salt and water must not be used for this purpose, 
as the soap or salt which remains in the bowel will prevent the silver 
salt from acting. . The strength of the solution employed should be 
1 dram to 3 pints (4.0-1440 cc) of water in colon trouble, and 
3 grains (0.2) to each 4 ounces (120.0) in rectal trouble. If the 



392 DRUGS 

latter condition is very obstinate and chronic, the strength may be 
increased to 5 grains (0.3) to each 4 ounces (120.0). 

Whenever nitrate-of-silver injections are used in this way, a solu- 
tion of salt and water should be ready for use, and injected if the 
action is too severe or as soon as it is thought that the drug has 
acted with sufficient thoroughness. 

Nitrate of silver was at one time thought to be of value in lateral 
and posterior spinal sclerosis, but rarely does good. 

Nitrate of silver has been largely used in epilepsy and chorea, but 
is now seldom so employed, and does little good in most cases. 

Pepper thought highly of the continual administration of nitrate 
of silver in pill form in the dose of | to \ grain (0.01-0.015) through 
the entire course of typhoid fever, and believed that it greatly modified 
the severity of the disease. 

Externally, nitrate of silver is used for many purposes, and will 
often prevent the pitting of smallpox if on the fourth or fifth day the 
vesicles are punctured by a needle dipped in a solution of nitrate of 
silver in the strength of 20 grains (1.3) to the ounce (30.0) of water. 
Others simply paint the skin over the eruption with a solution of 5 
to 10 grains (0.3-0.6) to the ounce (30.0), claiming that this method 
is equally effective and prevents inflammation and suppuration. 

Higginbottom has highly recommended the use of nitrate of silver 
upon erysipelatous inflammations, but the practice is not often resorted 
to, and is now supplanted by better measures. (See Erysipelas.) In 
other inflammations of a superficial character nitrate of silver is of 
great value. Painted in strong solution over the scrotum in the early 
stages of orchitis or epididymitis, it will often relieve the pain and 
diminish swelling, and felons may sometimes be aborted by its early 
application in concentrated solution over the surface of the finger. 

In all inflammations of the pharynx, larynx, fauces, and mouth 
solutions of silver nitrate may be used in varying strength. Some- 
times after slight exposure to cold or dampness the posterior wall of 
the pharynx suddenly becomes sore and raw, feeling as if the mucous 
membrane had been scarified. A solution of nitrate of silver will 
relieve this condition, and if it is employed in the strength of 60 
grains (4.0) to the ounce (30.0) of water, the application will be more 
efficacious and less painful than if weaker solutions are employed. 

In laryngeal phthisis a spray, from an atomizer, in the strength of 
J to 2 grains (0.03-0.12) to the ounce (30.0) of water may do good 
service. 

In ivhooping -cough Ringer recommends the use of a spray in the 
strength given above for the purpbse of relieving the cough in vio- 
lence and frequency and of obtaining a good night's rest. The appli- 
cations should be made when the stomach is empty, as they are apt 
to bring on retching. The tip of the atomizer must be within the 
mouth or the skin of the face will be stained. 

In the subacute stages of gonorrhea an injection of nitrate of silver 



NITRIC ACID 393 

of the strength of \ grain (0.03) to 3 ounces (90.0) of water is useful. 
(See Gonorrhea, Part IV.) 

In uterine ulceration and in leucorrhea when the cervix is boggy 
and tender, the application of the solid nitrate-of-silver stick is of 
service. Its use is often followed by headache about the vertex, and 
this in turn is to be relieved by 10-grain (0.6) doses of the bromides. 

In pruritus pudendi ml ani and vulva a solution of 4 to 6 grains 
to the ounce (0.25-0.4:30.0) should be painted with a camel's-hair 
brush over the parts to relieve the itching. The application is to 
be made from two to four times a day. 

Bed-sores may be aborted if, as soon as the skin reddens, an aqueous 
solution of nitrate of silver of the strength of 20 grains to the ounce 
(1.3-30.0) is applied with a brush to the part. For obvious reasons 
this measure often fails in paralytics. 

Boils which begin in a small limited papule with a surrounding 
area of inflammation may sometimes be aborted by painting a strong 
solution of this salt around them. 

In granular lids, conjunctivitis, and similar affections about the 
eye nitrate of silver in stick form or in solution is largely and success- 
fully employed. As a prophylactic for ophthalmia neonatorum it is 
invaluable, and in most cases a 1 per cent, solution is adequate. 
If infection is present, 2 per cent, should be used. The pain caused 
by the use of this salt in the eye can be modified by the addition 
to the ordinary watery solution of 15 per cent, of glycerin, which 
seems to increase the penetrative and antiseptic effect of the drug. 
(See Conjunctivitis.) 

When it is desired to remove nitrate-of-silver stains, they should 
be washed with a solution made of cyanide of potassium 2J drams 
(10.0), iodine 15 grains (1.0), and water 3 ounces (90.0); or dissolve 
15 grains (1.0) of corrosive sublimate in 7 ounces (210.0) of boiled 
water, add about 45 grains (3.0) of table salt (a scant teaspoonful) 
just before using, lay the stained materials in the mixture for about 
five minutes, and then wash them two or three times in pure water. 

Administration.— The dose of nitrate of silver is J to \ grain (0.01- 
0.015) in pill form. Mitigated caustic, or mitigated nitrate of silver 
(Argenti Nitras Mitigatus, B. P.), is composed of equal parts of 
nitrate of silver and potassium nitrate, and is good as a mild caustic. 

The drug when given continuously should be discontinued for two 
weeks at the end of the eighth week, as it is so slowly eliminated 
that it accumulates in the body and causes argyria; but Lewin and 
Soullier assert that the smallest aggregate amount on record which 
has produced argyria is 1 ounce. 

NITRIC ACID. 

Nitric acid (Acidum Nitricum, U. S. and B. P.), the strongest and 
most corrosive of the mineral acids used in medicine, is a clear liquid, 



394 DRUGS 

becoming slightly yellow with age. It should be kept in dark, 
glass-stoppered bottles. 

Physiological Action.— When in pure form, nitric acid acts upon 
the tissues of the body as a powerful caustic. Applied to the mucous 
membranes, well diluted, it acts as an irritant or astringent, and 
when taken internally it exerts a stimulating influence over the 
secretory glands of the stomach and small intestine. It does not 
tend to relax the bowels, as does nitro-hydrochloric acid. Continued 
for a long period of time in small doses, it is said to cause slight 
salivation and looseness of the teeth. Nitric acid coagulates albumin. 

Poisoning.— When nitric acid is taken in concentrated form, it 
produces a widespread gastro-enteritis, intense pain in the mouth, 
esophagus, and abdomen, and finally death from the inflammation 
induced or from collapse. If the patient survives the acute stages, 
he may die from secondary changes in the stomach and bowels, such 
as stricture or destruction of the peptic tubules. The stain made 
by the acid about the mouth and on clothing is deep lemon-yellow. 
Renal irritation is often a severe symptom, and the urine and the 
passages from the bowels may be bloody. 

The antidotes are any mild alkali, as magnesia, chalk, or plaster 
from the walls of the room, the use of oils and opium to relieve 
irritation, and the maintenance of bodily heat. 

Therapeutics.— Nitric acid is used externally in medicine as a 
caustic for chancres and chancroids, the surrounding tissues being 
protected by oils or ointments. 

Nitric acid may also be used on warts, in cases of gangrene to 
destroy the tissues, and on phagedenic ulcers. Whenever the acid 
is to be applied for such purposes, a solution of salt and water 
should be at hand to neutralize the effects as soon as it has acted 
deeply enough. Nitric acid is also used externally in a dilute form, 
5 to 30 minims to the ounce (0.3-2.0:30.0) of water, as a stimulant 
and astringent to indolent ulcers. 

Internally, nitric acid is used as a tonic and astringent. In the 
oxalic-acid diathesis when oxaluria is present, nitric acid will give 
relief when nitromuriatic acid cannot be obtained, although the 
latter is preferable. When small ulcers exist in the mouth or stoma- 
titis is present, 3 minims (0.2) of nitric acid at a dose, in water, will 
often be of service, but it should be taken through a tube to protect 
the teeth. In gastric indigestion in which, sometimes after a meal, 
undigested food regurgitates into the mouth, a few drops of nitric 
acid in water after meals will often give relief. In intestinal dys- 
pepsia coming on some hours after meals, and in which not only 
discomfort but pain may be felt in the hypochondrium, nitric acid 
with some bitter tonic is most efficient, and it will often cure the 
green diarrhea of children, particularly that met with in summer, 
bringing about these changes not only by its astringent power, but 
also by its stimulating effect on the intestinal glands. Combined 



NITRITE OF POTASSIUM 



395 



with some good pepsin, it will give relief in the chronic diarrhea of 
children associated with lientery, and in which the stools may be 
pasty or watery and at the same time ill-smelling. 

Ringer recommends the employment of nitric acid in the treatment 
of piles. The strong acid should be used, and simply touched to one 
or two points, not swept over the whole surface. The pain is slight, 
or none at all may be felt. A slough results, and finally comes away, 
leaving a cicatrix which as it contracts diminishes the size of the pile. 

The same author also states that a lotion of nitric acid in the 
proportion of \ to 1 dram to a pint (2.0-4.0:480 cc) of water is 
of sendee in bleeding hemorrhoids, arresing the bleeding, constringing 
the parts, and relieving the sensation of weight and fulness so often 
a pressing symptom. 

The dose of dilute nitric acid (Acidum Nitricum Dilutum, B. P.) 
is 3 to 15 minims (0.2-1.0), well diluted, and taken through a tube 
to protect the teeth. 

An exceedingly strong preparation, Acidum Nitricum Fumans, is 
official in the B. P. 

NITRITE OF POTASSIUM. 

Nitrite of potassium is a salt used largely in modern medicine to 
take the place of nitroglycerin, as it possesses greater stability, and 
is therefore more lasting in its effects (Fig. 56). It is used for the 



Minutes Hour 

1 15 30 1 




Sodium 
Nitrite 
Nitro- 
glycerine 



21annitol 
Nitrate 



Erythrol 
Tetranitrate 



Fig. 56. — Showing length of effect of different nitrites. 



relief of angina pectoris or heart-pang, in the treatment of gastralgia 
and in epilepsy. The dose is from 3 to 5 grains (0.2-0.3), although 
much larger doses have been employed. These larger doses are, 
however, not devoid of danger. Nitrite of potassium is eliminated 
by the lungs and by the kidneys as a nitrate. (See Nitroglycerin.) 



Cobalto-nitrite of Potassium. 

This preparation has been employed successfully as a substitute 
for the nitrite of potassium. As it is a more stable compound, it is 
less rapidly broken up in the system, and so exercises a more pro- 



396 DRUGS 

longed influence. For this reason it does not act so vigorously or 
suddenly, which is a great advantage in some cases. Its use is 
identical with that of the rest of the nitrite group. The dose is J 
grain (0.03) every three hours. 

NITRITE OF SODIUM. 

Sodium nitrite (Sodii Nitris, U. S. and B. P.) is used for the same 
purposes as nitrite of potassium in the dose of 1 to 2 grains (0.06- 
0.12) given in pill or cachet. If exposed to the air it deliquesces, 
gradually oxidizes, and becomes unfit for use. This is probably the 
best of all the nitrite preparations for cases of persistent high arterial 
tension. It is best given in capsule with sodium bicarbonate. (See 
Nitroglycerin.) 

NITROGLYCERIN. 

Nitroglycerin, sometimes called trinitrin or glonoin, is a com- 
pound which, in its pure state, is used largely as an explosive, but 
it is employed in medicine in a dilute form as a useful drug in those 
instances where a somewhat rapid and powerful effect is to be exer- 
cised over the vascular system. As its influence lasts but a short 
time, it should be given every three or four hours. Its physiological 
action is identical with that of the other nitrites, such as the amyl 
nitrite (which see), except that it is not so violent or fugacious as 
the latter nor so persistent in its effects as the nitrites of sodium and 
potassium. The dose is 1 to 2 minims (0.05-0.1) of a 1 per cent, 
alcoholic solution (Spiritus Glycerylis Nitratis, U. S. P.) in a little 
water or in a pill, after the patient has taken the remedy for a con- 
siderable period of time, as much as 60 minims has been administered, 
as the system rapidly becomes accustomed to its effects. Often good 
results are obtained only by giving ascending doses. It is note- 
worthy that patients rapidly become immune to the drug, and Read- 
ing has recorded a case in which, after a year of treatment, 1 dram 
(4.0) of a 10 per cent, solution was taken daily with good effect. 
The author has given as much as 1J grains a day. 

The drug is largely employed in angina pectoris (see Part IV) , and 
sometimes in epilepsy and chorea and in gastralgia. J. M. DaCosta 
and others have highly commended this drug in the treatment of 
chronic parenchymatous nephritis, as it distinctly decreases the excre- 
tion of albumin from the kidneys. In interstitial nephritis, with 
cardiac disturbance resulting from the renal changes, in which there 
is a marked increase in arterial pressure, so that auscultation reveals 
at the second right costal cartilage an accentuated second sound due 
to the forcible closure of the aortic leaflets, nitroglycerin often pro- 
duces a good effect by reducing the pressure and relieving the heart 
of strain. This use of the drug is one of its most important appli- 
cations. (See article on Heart Disease, in Part IV.) It is when 



NITRO-HYDROCHLORIC ACID 397 

attacks of angina pectoris seem to be accompanied or preceded by 
marked vascular spasm that nitroglycerin is chiefly indicated. 
Nitroglycerin given hypodermically in the dose of yj-^ to -fa grain 
(0.0006-0.0012) is one of the best remedies for hemoptysis. (See 
Amyl Nitrite.) 

In cases of asthma dependent upon spasm and engorgement of the 
mucous membranes of the bronchial tubes it is serviceable. Hum- 
phreys asserts that nitroglycerin is a most valuable drug in vomiting 
of all kinds, except that of pregnancy and peritonitis. Given in the 
dose of 2iro g ra i n (0.0003) nypodermically with morphine it prevents 
the after-nausea sometimes produced by that drug. 

Nitroglycerin usually causes a considerable increase in urinary 
flow by reason of the relaxation of the renal bloodvessels which it 
produces, particularly those vessels forming the Malpighian tuft. 

Because nitroglycerin relaxes arterial tension and so relieves the 
heart of a certain amount of labor in cases characterized by high 
arterial tension, thereby doing good when the heart is tired because 
of the labor required of it, many physicians have come to employ 
it as a cardiac stimulant in acute diseases without high tension of 
the bloodvessels. There is no justification for this use of the drug, 
for it is not a stimulant. 

The 1 per cent, solution used in medicine is too weak to be explosive. 
Tablets of nitroglycerin (Tabellce Trinitrini, B. P.) each contain t ^-q- 
grain (0.0005). The Spiritus Glycerylis Nitratis, IT. S., is a 1 per 
cent, alcoholic solution of glyceryl trinitrate. It should be kept in 
tightly stoppered tins, never in glass, and be stored in a cool place, 
away from heat. Its explosiveness is in direct ratio to the evapora- 
tion of its alcohol. If it is spilled in any quantity so that the alcohol 
can evaporate and so leave nitroglycerin in concentrated form it 
should be decomposed by pouring over it a solution of potassium 
hydroxide. The dose of the spirit is the same as that of the watery 
solution, namely, 1 to 2 minims (0.05-0.1). Liquor Trinitrini, B. 
P., is practically identical with the spirit just named, and is given 
in the same dose. 

Erythrol Tetranitrate. 

Erythrol tetranitrate is a white crystalline substance, soluble in 
alcohol, but insoluble in water. It is explosive on percussion or 
trituration, and is employed in the place of nitroglycerin for the 
purposes just named. It is not so useful, however, and is slower in 
effect. Its dose is \ to \ grain (0.015-0.03), given in solution or in 
tablets. 

NITRO-HYDROCHLORIC ACID. 

Nitro-hydrochloric acid (Acidum Nitro-hydrochloricum, U. S.) is 
a liquid giving off a distinct odor, possessing caustic power, which 
stains the tissues of the body a light yellow. It is official in the 
form of the dilute acid (Acidum Nitro-hydrochloricum Dilutum, IT. S. 



398 DRUGS 

and B. P.), in which form it is useless except as an ordinary acid. 
When it is desired to use the acid for its own peculiar effects,, the 
official dilute acid ought always to be supplanted by the freshly 
mixed strong acid, which should be of an orange color. If this can- 
not be obtained, the physician should prepare the compound himself 
by adding 4 parts of medicinally pure nitric acid to 16 parts of 
hydrochloric acid, and allowing the mixture to stand in an open 
bottle until fumes are no longer given off in excess, when it should 
be tightly corked and kept in a dark place. This acid should be 
freshly prepared every few days. 

Poisoning.— The symptoms caused by poisonous doses are those 
of violent gastro-enteritis with vomiting and purging of bloody 
materials. Death may occur from perforation of the alimentary 
canal, from inflammation of the abdominal viscera, and from destruc- 
tion of the peptic tubules or constrictions of the esophagus or bowel. 
The treatment consists in the use of alkalies, such as magnesia, lime, 
plaster, soap, and oils, with opium to allay irritation. The use of 
external heat to prevent collapse is also to be resorted to. 

Therapeutics.— Nitro-hydrochloric acid is an invaluable remedy 
in many cases of indigestion arising either in the stomach or bowels, 
as it acts as a tonic and stimulant to secretion. Upon the biliary 
flow its action is marked, and it may even cause bilious purging if 
administered in full doses for some days. It is therefore largely used 
in hepatic torpor, either acute or chronic, and in the early stages of 
hepatic cirrhosis should always be resorted to. In the chronic hepatitis 
of hot climates it is exceedingly useful, but it is not to be employed in 
acute sthenic hepatitis, as it is a stimulant to the liver, which, under 
these conditions, needs quieting. When used in chronic hepatitis it 
should be given in full dose and pushed to its physiological limit, 
as evidenced by the bilious purging produced or by signs of gastro- 
intestinal irritation. 

A useful additional means for obtaining the beneficial effects of 
this acid is to use it by means of the foot-bath or general bath. As 
used by Johnson in India, the acid for this bath is prepared by slowly 
and carefully adding together 2 parts of nitric acid and 3 parts of 
hydrochloric acid, and after twenty minutes mixing carefully with 
these distilled water 5 parts. For a general bath (in a wooden tub) 
take 5 pailfuls of water, 64 fluidounces (2 liters +) of the acid mixt- 
ure, and enough boiling water to raise the temperature to 98° F. 
Keep the patient in the bath twenty minutes. Then rub him thor- 
oughly with warm towels and place him in a dry, warm bed. For 
the foot-bath add 6 ounces (180.0) of the acid to 2 gallons (7 liters) 
of water at 98° F., and bathe the thighs and calves of the legs for 
twenty minutes with a sponge wet with the mixture. This is a very 
useful treatment, according to Stille, for cases of alcoholic hepatic 
torpor. If in either case the skin becomes irritated, less acid is to 
be used. 



NITROUS OXIDE 399 

In ordinary so-called biliousness, which is not biliousness but 
intestinal indigestion, this acid is often of great service. (See Indi- 
gestion and Biliousness.) It is also of value in lienteric diarrhea 
where the dysentery results from defective secretory action on the 
part of the glands which pour out the proper fluids for digestion. 

Another very important action of nitro-hydrochloric acid is the 
remedial influence it exerts in persons suffering from oxaluria, par- 
ticularly if this be associated with melancholia or great mental 
depression. 

Administration.— The strong, freshly mixed acid should be given 
to the adult in the dose of 3 to 5 minims (0.2-0.3) three times a day, 
well diluted, and taken through a tube, after meals. If the patient 
is intelligent, he should be ordered | ounce (16.0) of the pure acid 
and told how to drop it. If he is not, the physician should order 
it partly or entirely diluted in the prescription, and in so small an 
amount that it will be renewed before it loses any of its power. 
Warning should be given of its effects on clothing with which it 
may come in contact, and care should be taken that the bottle is 
held some distance from the face when the cork is withdrawn, as 
the acid, if freshly mixed, may spurt and burn the eyes and skin. 

NITROUS OXIDE. 

Nitrous oxide, or Nitrogenii monoxidum, U. S., is sometimes called 
protoxide of nitrogen, or "laughing gas." Its power to relieve pain 
was first recognized by Sir Humphrey Davy more than one hundred 
years ago. As with ether, so with nitrous oxide, its first use as a 
surgical anesthetic was by an American, Horace Wells, a dentist. 

This gas is obtained by a complicated process which requires the 
use of such cumbersome apparatus that its manufacture is out of 
the question for the ordinary practitioner of medicine, while the 
fact that several firms prepare the gas and market it in cylinders 
ready for use renders its preparation on a small scale unnecessary. 
The gas is devoid of odor, but possesses a slightly sweet taste. It 
may be kept in gaseous form, or in liquid form and allowed to become 
gaseous as it is used. Owing to the symptoms sometimes produced 
in persons inhaling this gas, it has received the popular name of 
"laughing gas," but a condition of hilarity is rarely seen when the 
inhalations are full and deep, and only comes on, in the majority 
of cases, when the gas is given in small amounts or inhaled very 
slowly. 

Physiological Action.— According to some careful studies upon the 
action of this gas (Kemp), it has no direct effect on the heart and 
vasomotor system, but indirectly it causes a rise of arterial pressure 
by the slight asphyxia which is produced. The anesthesia is due in 
part to the non-oxygenation of the blood during the time the gas 
is in this fluid, but the gas chiefly produces anesthesia by a direct 



400 DRUGS 

action on the cerebral cortex. It is a curious fact that the con- 
junctival reflex is often preserved after general anesthesia is present. 
It has been thought that the use of this drug produces temporary 
glycosuria, but recent studies render this doubtful, to say the least. 
When permanent glycosuria has been produced, some injury to the 
vascular system in the region of the diabetic center in the floor of 
the fourth ventricle has in all probability occurred. Nitrous oxide 
gas rarely produces any disagreeable after-effects, save a slight light- 
headed sensation or dizziness lasting for a few hours. 

Therapeutics.— When used properly, the patient is directed to take 
long, deep inspirations from the tube placed in the mouth, the nose 
being held so that the nostrils are closed, or a mask, provided with a 
valve for the escape of the expired air, is applied over the mouth and 
nose. The gas is then allowed to enter the mask and is inhaled from 
it. Under these circumstances the face becomes for a moment 
flushed, then of a deadly pallor, and finally the jaw drops if the 
effect is complete. At this time anesthesia is complete and the 
operation is to be rapidly performed. 

Owing to the fact that when pure it is devoid of depressant effects 
and irritant properties, this gas can be used when ether and chloroform 
are contraindicated. 

Nitrous oxide is a useful anesthetic in all minor operations, such 
as opening an abscess, boil, or felon, or even amputating a digit. It 
is used by many surgeons at the present time for the purpose of 
beginning an anesthesia which is to be continued by ether or chlo- 
roform, since the rapidity with which it produces anesthesia prevents 
the disagreeable preliminary symptoms induced in many persons by 
these drugs. This is particularly advantageous in nervous women 
and children. 

The gas possesses two disadvantages: the first of which is its 
brevity of action, the other the difficulty in carrying it from place 
to place. It possesses a great advantage in almost absolute safety, 
very few deaths having been caused by it directly. It is the safest 
of all anesthetics, not even excepting cocaine, which latter drug has 
largely supplanted the gas for many minor surgical operations. 

When teeth are to be extracted, a plug or cork is placed between 
the jaws before the gas is given to keep them apart. The cork 
should always be attached to a string, so that if it slips into the 
back part of the mouth it can be withdrawn before it chokes the 
patient. Jaw forceps may also be employed. 

The combination of nitrous oxide and oxygen-gas is becoming 
more and more popular for many major operations, since the oxygen 
enables the anesthetist to prolong the anesthesia almost indefinitely 
and the patient is never more than "just under." By the simul- 
taneous use of oxygen the rise of blood ordinarily induced is put 
aside. So far as surgery is concerned, the use of nitrous oxide alone 
has been almost completely supplanted by the use of the combined 



NITROUS OXIDE 



401 



gases. Particularly is it useful if very weak solutions of some local 
anesthetic like Schleich's fluid or a 0.25 per cent, procaine solution 
is used, the entire field of the operation as it proceeds being infil- 
trated as nearly as possible along the lines of its nerve supply. Many 
physicians, particularly those attached to maternities or hospitals 
in which assistants trained in the use of this gas are present, are 



ETHER CONTAINER 




Fig. 57. — Nitrous oxide-oxygen-ether apparatus assembled for use. (Connell.) 



using with good results nitrous oxide gas to relieve the pains of 
childbirth. If given skilfully there is no danger to the mother and 
but little danger to the child. Asphyxia of the newborn may be 
present if it is carelessly used. Many anesthetists use an apparatus 
by which nitrous oxide, oxygen and ether can all be used. (See 
Fig. 57.) 
26 



402 DRUGS 

The following classes of persons, according to Hewitt do better 
with the mixture of oxygen and nitrous oxide than with the nitrous 
oxide alone: 1. Children (who, with nitrous oxide alone, are liable to 
inconvenient jactitation). 2. Anemic and debilitated patients, who, 
like children, quickly exhibit muscular contraction, and in addition 
to this, remain but a very short time under the influence of nitrous 
oxide alone. 3. Anyone who has previously exhibited great insus- 
ceptiblity to nitrous oxide per se (such patients are difficult subjects 
to manage in dental practice because of the short period of available 
anesthesia). 4. Patients who, under nitrous oxide alone, have exper- 
ienced highly unpleasant sensations. 5. Patients very advanced in 
years. 6. Patients with very large tonsils. 7. Patients suffering 
from heart or lung affection. 

Administration.— More training and skill are needed to produce 
satisfactory anesthesia for surgical purposes by nitrous oxide than 
when ether is employed. When nitrous gas is used as an anesthetic 
it must be given without any air being admitted to the inhaler. 
The inhaler fits closely to the face and by means of valves the gas 
gains access to the lungs during inspiration, but during expiration 
the expired air and gas escape into the room or into a rubber bag 
so that rebreathing may be practised. Whenever it is desirable to 
continue nitrous oxide anesthesia for more than a few moments, it 
is advantageous to combine with the nitrous oxide gas a small pro- 
portion of oxygen, since in this way asphyxia is prevented. The 
oxygen gas, however, must be given moderately or it will interfere 
with the full effects of the nitrous oxide. These gases are best 
administered by some such apparatus as that shown in Fig. 57. 
Two of the tanks (colored red) contain pure oxygen and the others 
(colored blue) are filled with nitrous oxide. 

Under the openings marked " oxygen meter" and "N 2 meter," 
which are covered with glass, there are disks, each of which is actu- 
ated by the flow of gas. On the periphery of each disk there is a 
scale which enables one to judge the rate of gas flow. The disk 
measuring the oxygen flow is calibrated to a flow in steps of 0.1 
liter per minute up to 2.5 liters per minute. The nitrous oxide disk 
is calibrated in steps of 1 liter per minute up to 12 liters per minute. 
The calibration of the disks differs because the amount of oxygen 
employed is far less than that of nitrous oxide. By these disks 
the quantity of the oxygen and nitrous oxide which a patient is 
receiving can be estimated, and the quantities varied according to 
the degree of anesthesia and the condition of the patient. By means 
of the stop-cock shown in the illustration ether can be added to the 
gases and, by means of the " safety heater," the ether may be warmed 
without danger of exploding. During anesthesia a flow of oxygen 
amounting to about 0.5 liters per minute is usually employed, but 
larger quantities may be used if need be. The nitrous oxide is 
usually given at the rate of from 6 to 10 liters per minute. 



NUTMEG 403 

If the operation is a prolonged one, it is advisable to permit some 
atmospheric air to enter at the sides of the inhaler occasionally in 
addition to the oxygen. 

Contraindications.— The gas ought not to be given to those who are 
advanced in years or have atheromatous bloodvessels, since the rise 
of arterial pressure consequent upon the asphyxia may rupture a 
cerebral bloodvessel and thereby cause an apoplexy; but if oxygen 
gas is properly given with it this danger is largely put aside, for 
except in rare cases the pressure does not rise. 

NOVASPIRIN. 

Novaspirin is a white powder possessing a faint acidulous taste, 
but without odor. It is practically insoluble in water, but readily 
so in alcohol. It contains 62 per cent, of salicylic acid and its chemi- 
cal name is methylene-citryl-salicylic acid. As it is supposed to pass 
through the stomach unchanged, it may be employed interchange- 
ably with salol or aspirin when the gastric disturbances produced by 
the ordinary salicylates contraindicate their use. When it comes in 
contact with the alkaline juices of the intestines it is decomposed 
into salicylic acid and methylene citric acid. It is less irritating 
than aspirin. 

The uses of novaspirin are practically identical with salol and 
aspirin, namely: in influenza, tonsillitis, intestinal fermentation, neu- 
ralgia, and in both muscular and acute articular rheumatism. 

The ordinary dose for an adult is from 8 to 15 grains (0.5-1.0). 
As much as 60 grains (4.0) or more may be given in twenty-four 
hours, if necessary, to combat rheumatism. 

NOVOCAINE. 

(See Pkocaine.) 

NUTMEG. 

Myristica, U. S. and B. P., or nutmeg, is the kernel of the ripe seed 
of Myristica fragrans, an East and West Indian plant, mace being 
the outside covering of the same. Nutmeg is a soporific and nervous 
sedative, exercising a peculiar influence over the cerebrum. It is 
also used as a flavoring substance in somnifacient mixtures, and is 
of value in prescriptions for serous diarrhea. The oil (Oleum Myris- 
ticw, U. S. and B. P.) is given in the dose of 1 to 3 minims (0.05- 
0.2). The spirit or essence (Spiritus Myristicce) is used in the dose 
of 1 to 2 fluidrams (4.0-8.0). 

Several instances of poisoning by nutmeg are reported; a severe 
case by Dr. Reading, of Woodbury, N. J. The symptoms closely 
resemble those produced by excessive doses of cannabis. 



404 



DRUGS 




NUX VOMICA. 

Nux vomica (U. S. and B. P.) is the seeds or beans of Strychnos 
Nux-vomica, an East Indian tree, yielding when assayed by the 
U. S. P. process not less than 2.5 per cent, of the alkaloids of nux 
vomica. It contains two ' alkaloids, strychnine and brucine, and 
depends largely for its medicinal power on the former. For this 

reason the statements made in regard 
to the physiological action of strych- 
nine may practically be considered as 
applicable to the entire drug. 

Physiological Action.— When strych- 
nine is given to man, or the lower 
animals in full medicinal dose it in- 
creases reflex activity, respiratory rate, 
pulse-force, arterial pressure, the acuity 
of smell, vision, and hearing, and causes 
general systemic irritation or excite- 
ment. 

Nervous System.— On the nervous 
system strychnine exerts its chief influ- 
ence. It excites the spinal cord in its 
motor tracts, and probably increases 
the receptive activity of the sensory 
centers. It also has some slight influ- 
ence in increasing the conductive power 
of the motor and sensory nerves. 

In overdose strychnine produces 
spinal or tetanic convulsions by an 
action exerted on the spinal cord. 
When enormous doses are given intra- 
venously, total paralysis, resembling 
that caused by curare ensues, and if 
artificial respiration is not used the 
animal dies from failure of respiration. 
If death takes place from the effects of 
the drug, the motor nerves are found 
to be depressed, partly as the result 
of the poisonous action of the strych- 
nine, and partly as the result of the exhaustion of the nerve-trunks 
by the convulsing impulses which they have carried (Fig. 58). 

Circulation.— Nux vomica increases the force of the pulse-beat 
and the pulse-rate by a stimulation of the heart-muscle and its 
glanglia, while the rise of arterial pressure which it causes is. due 
to stimulation of the vasomotor center. If very poisonous doses 
are injected intravenously, a fall of arterial pressure occurs instead 
of a rise, which is due to vasomotor depression and paralysis. 







Fig. 58. — A, nux vomica stimu- 
lates the motor tracts in the spinal 
cord and to a slight extent the 
nerve-trunks; B, in large, poison- 
ous doses it depresses the motor 
nerve-plate in the muscle and 
exhausts the nerve-trunks. 



NUX VOMICA 405 

Respiration.— Strychnine is one of the most constant and power- 
ful stimulants of the respiratory center that we have, and it not only 
increases the rate of respiration, but also the respiratory capacity. 

Temperature.— Ordinary doses have no effect upon temperature, 
but poisonous doses may raise it by reason of the convulsions. 

Elimination.— Strychnine is eliminated from the body by the 
kidneys as strychnine and strychnic acid. Most of it is oxidized 
and destroyed by the liver. 

Therapeutics.— Nux vomica, or its chief alkaloid strychnine, is 
used for several purposes in medicine. Owing to its bitter character, 
it may be employed as a simple bitter tonic or as one especially 
influencing the nervous system. It may also be used as a respiratory, 
cardiac, and ocular stimulant. 

In cases of functional nervous atony, or depression, strychnine does 
good; but in organic disease of the nervous system, if used during 
the period of acute inflammation, as, for example soon after an 
apoplexy or in acute infantile palsy, it is distinctly harmful. Some 
persons who have suffered from apoplexy can never take the drug 
without a spasm coming on in the paralyzed part or parts, probably 
through irritation of the degenerated pyramidal tracts. In acute 
or subacute neuritis strychnine ought never be used, as the nerves 
are already inflamed, and are not to be still further irritated by the 
employment of nerve excitants. In progressive lead palsy large doses 
of strychnine should be constantly used to check the progress of 
the disease, iodide of potassium also being employed to cause 
elimination of the lead. 

In amaurosis dependent upon the excessive use of tobacco or 
alcohol strychnine is almost a specific, and in eye-strain resulting 
from insufficiency of the ocular muscles it does great good, curing 
the insufficiency and improving the general condition of the muscles. 
According to de Schweinitz, the patient should use ascending doses 
of the tincture of nux vomica, beginning with 10 minims (0.65) 
three times a day, and increasing the amount 2 minims (0.1) a dose 
until distinct physiological effects are produced. Sometimes 60 
minims (4.0) or more may be taken in twenty-four hours. 

Experiments by the author indicate that constantly increasing 
doses, instead of decreasing the person's susceptibility to the drug, 
actually increase it, so that a large but moderate dose produces 
greater effects after some days of use than a full dose does at first. 

In pneumonia and all other acute diseases in which sudden col- 
lapse is liable to occur strychnine is of the greatest service at the 
time of need. Often it will pull the patient out of a sinking attack 
which seems certain to end in death. It should be used freely by 
the hypodermic needle, and is often aided in producing its good effects 
by the addition of yi-Q to t Jq- grain (0.0004-0.0006) of atropine to 
each injection. (See Pneumonia and Shock.) 

The author desires to protest most emphatically against the 



406 DRUGS 

common practice of the day, which consists in the use of strych- 
nine as a circulatory stimulant through prolonged exhausting illness. 
It is essentially a whip to the flagging heart, to be used at a crisis, 
but not continued for days. Cases are constantly seen in which 
the persistent use of the drug in fever produces a rapid running 
pulse and great nervous irritation and prolongation of the febrile 
movement. 

There is no drug known which is so antidotal to the effects of 
overdoses of chloroform as is strychnine. In cases of sudden acci- 
dent, with arrest of the heart or respiration during the use of this 
anesthetic the physician should give an intramuscular injection of 
yq grain (0.006) of strychnine as a powerful, rapidly acting cardiac 
and respiratory stimulant, which dose may be repeated in ten minutes 
if no effect is produced. 

The use of strychnine as a stimulant in surgical shock has been 
criticized on the ground that it is valueless if the vasomotor center 
is paralyzed. This would hold true if the center was paralyzed; in 
most cases, however, it is only depressed, and strychnine does good 
if the operation or accident is past. Given before operation to 
prevent shock its use is unwise in that, by stimulating and exciting 
the nervous system, it renders it more susceptible to shock and 
injury. Oftentimes the apparent collapse of a recuperating patient 
is due rather to intense nausea than to the shock, and the free use 
of this drug is not necessary. 

It is a better antidote to opium than is belladonna. 

In dyspnea from any cause, such as that of old persons suffering 
from winter cough or bronchorrhea, in emphysema, phthisis, and in 
shortness of breath, strychnine is of service, and it is a valuable drug 
for the treatment of opium poisoning, because it preserves the reflexes 
and stimulates the respiratory center. 

In atony of the bowels strychnine is of service, and it is to be added 
to purgative pills to avoid their depressing after-effects on the 
intestines. 

In cases of hemiplegia, after the acute stage is passed, strychnine 
may be used to keep up the nutrition of the limbs, which are para- 
lyzed; but if the paralysis be due to disease of the trophic cells in 
the spinal cord, it does little good except to stimulate the remaining 
cells to greater effort. 

According to Ringer, sick headaches, due to errors in diet and 
without much nausea, can be relieved for the day by the use of 1 
minim (0.05) of the tincture of nux vomica in a teaspoonful (4.0) 
of water every five or ten minutes until 10 minims (0.6) are taken. 

Strychnine possesses no curative properties in chronic alcoholism. 
Owing to its powerful stimulant properties it may temporarily brace 
the nervous system, but its prolonged use is dangerous. It should 
be employed temporarily only to combat great depression of the 
system. 



NUX VOMICA 407 

Untoward Effects.— Care should be exercised in giving strychnine 
to children, as they are more susceptible to the drug than are adults. 
The proper beginning dose of strychnine by the mouth for a child of 
five or six years is not more than yj-g- grain (0.0006). In some cases 
of exhausting disease the prolonged use of full doses of strychnine 
may produce a talkative delirium with great peevishness, and, if 
the drug is continued, this condition may pass into a state of tem- 
porary insanity. Brunton asserts that mix vomica may induce 
malarial chills in those predisposed to them. He also asserts that 
strychnine acts more powerfully when given by the rectum than 
by the mouth. This is doubtful. 

Administration.— The extract of nux vomica (Extractum Nucis 
Vomica, U. S., and Extractum Nucis Vomica? Siccum, B. P.) should 
contain about 16 per cent, of alkaloids and is given in the dose of J 
to i grain (0.01-0.015), \ to 1 grain (0.015-0.06), B. P.; the fluid- 
extract (Fluidextr actum Nucis Vomica?, U. S., Extractum Nucis 
Vomica? Liquidum, B. P.) contains about 2.5 gram of alkaloids in 
100 cc and is given in the dose of 1 to 5 minims (0.05-0.3); the 
tincture (Tinctura Nucis Vomica?, U. S. and B. P.), containing 
about 0.25 gram of alkaloids in 100 cc is used in the dose of 5 to 
30 minims (0.3-2.0), 5 to 15 minims (0.3-1.0), B. P. Strychnines 
Sulphas (U. S.), Strychnina? Nitras (U. S.), and Strychnina? Hydro- 
chloridum (B. P.) are given hypodermically in the dose of -£$■ to -^V 
grain (0.002-0.003), and by the mouth in the same amounts. In 
cases of severe surgical shock as much as J grain (0.015) may be 
used hypodermically. The B. P. recognizes a solution (Liquor 
Strychnina? Hydrochloride ; dose, 2 to 8 minims (0.1-0.5). 

Poisoning.— When a poisonous dose of strychnine is taken, it may 
act either suddenly or gradually. If suddenly, the man or animal 
may, without premonition, be thrown several feet and become rigid 
by contraction of the muscles. If onset is gradual, some stiffness 
at the back of the neck and uneasy startings may precede the general 
nerve-storm. 

The convulsions are tetanic, or, in other words, tonic, and the 
body is thrown into opisthotonos: that is, resting on the head and 
heels at each convulsion. Rarely the trunk is twisted sidewise or 
the flexion of the body is forward (emprosthotonos) . The eyes are 
open and fixed, the corners of the mouth drawn back into risus 
sardonicus, and reparation during a severe convulsion is impossible 
owing to the respiratory muscles being in a state of tetanic rigidity. 

The slightest noise, draught of air, or touch may cause a convul- 
sion or convulsion after convulsion, because the sensory impulse, 
reaching the spinal cord, causes a spasmodic motor impulse to be 
sent out to the muscles. 

The convulsions are not absolutely continuous, but periods of utter 
or partial relaxation occur, during which the patient breathes easily. 
The cramp-like contractions of the muscles are exceedingly painful. 



408 DRUGS 

The patient either dies of cramp asphyxia— that is, through failure 
of respiration because his chest muscles are locked in spasm— or, 
much more rarely, from exhaustion. After death the posture of 
the body may or may not be typical of the strychnine spasm. Usu- 
ally it is not typical, although the severe muscular exertion of the 
attack may result in the early development of marked rigor mortis. 
Reichert has shown that it requires five hundred times the ordinary 
fatal dose of strychnine to cause death in animals if artificial respi- 
tion is properly maintained. The average fatal dose for an adult 
is 1J to If grains (0.1-0.12). Death has occurred from \ grain (0.03) 
and recovery after swallowing 19 grains (1.25) . Hewlett has recorded 
a case in which 15 grains (1.0) were swallowed yet recovery ensued. 

Treatment of Poisoning.— The attendant should give at once, if 
no symptoms have appeared, inhalations of nitrite of amyl, and mean- 
while employ the stomach-pump, using the nitrite to prevent any 
convulsive tendencies during the operation. Draughts of water con- 
taining tannic acid, as the chemical antidote, are to be administered, 
and after the stomach is washed out 60 grains (4.0) of bromide of 
potassium and 20 grains (1.3) of chloral in solution are to be given. 
These are the physiological antidotes, for the bromide of potassium 
depresses the sensory tracts of the spinal cord, and the chloral 
depresses the motor tracts. If the convulsions prevent swallowing, 
the patient should be chloroformed with care, and the physiological 
antidotes given by a stomach tube or in starch-water by the rectum, 
muscular relaxation being maintained by the anesthetic until the 
drugs are absorbed. Ether cannot be used as a relaxant, as it is too 
irritant and too slow. Nitrite of amyl is a physiological antidote, 
but it is useless if a complete convulsive attack is present, as it cannot 
be inhaled if the chest is immovable. Neither can any other relaxant, 
such as chloroform, be used under these circumstances. These drugs 
should be gently given between the paroxysms. If relief does not 
occur, the nitrite of amyl should be injected hypodermically. Cutler 
and Alton have shown that intraspinal injections of magnesium 
sulphate are advantageous. (See Magnesium Sulphate.) 

While a light touch may produce a spasm, it is said that a firm, 
hard grasp of the limb often relieves the pain of the cramp. Sensa- 
tion and consciousness are preserved in strychnine poisoning unless 
the asphyxia obtunds them. 

Differential Diagnosis.— The convulsions of strychnine-poison- 
ing do not resemble those of epilepsy, because they are distinctly 
tonic and never clonic. From tetanus, strychnine-poisoning is to be 
differentiated by the fact that in tetanus the locking of the jaws 
comes first, while in strychnine poisoning it comes last. The con- 
vulsions of tetanus rarely, if ever, completely relax, while those of 
strychnine do have periods of relaxation. There is a different history 
in each case— in one perhaps of an injury, as of a nail run into the 
foot; in the other, of a dose of poison having been swallowed. 



OPIUM 409 

The differential diagnosis of strychnine-poisoning from hysterical 
convulsions is more difficult. The convulsions are rarely so persist- 
ently tonic in hysteria, and the peculiar expression of the hysterical 
face is often seen in such cases. The history of the patient, if obtain- 
able, will throw much light on the case and aid very materially in 
the differentiation of the two conditions, while the peculiar varia- 
tions in cutaneous sensibility, such as areas of hyperesthesia and 
anesthesia, which are so characteristic of hysteria, may render the 
diagnosis possible. 

As the treatment of all these states is virtually identical, the 
employment of the measures just suggested may be resorted to in 
each instance, and the diagnosis made afterward. 

OPIUM. 

Opium (U. S. and B. P.) is the juice or milky exudation appear- 
ing on the surface of the unripe capsules of white poppy, or Palaver 
somniferum, a native plant of Asia, now grown in many other parts 
of the world. 

Good opium, according to the U. S. P., should contain at least 9.5 
per cent, of anhydrous morphine. 

The chemical composition of this drug is very complex, no less 
than seventeen alkaloids having been obtained from it, the most 
important of which are morphine, codeine, narcotine, thebaine, nar- 
ceine, papaverine, pseudomorphine, and laudanine. It also contains 
meconic acid and meconine. 

Physiological Action.— The action of opium upon man and the lower 
animals varies with the degree of intelligence or cerebral' develop- 
ment. It quiets the brain and excites the spinal cord. 

Nervous System.— The dominant action of opium upon man is to 
produce nervous sedation in small doses and sleep when given in 
larger amounts. Sometimes, however, in persons who are accus- 
tomed to its use, it produces a state of restless insomnia or quiet, 
wakeful apathy. When given to frogs, it often produces tetanic 
convulsions, owing to its primary stimulant effect on the spinal 
cord. In dogs it increases the reflexes and produces drowsiness, and 
in man, sleep. If, however, the patient be a member of one of the 
lower races or a young child, the spinal irritation may be as manifest 
as the cerebral sedation. If large doses are given, sleep is produced 
in all animals, and both the brain and spinal cord are depressed. 
The sensory nerves are also markedly benumbed, and the motor 
nerves may finally be rendered inactive. 

Circulation.— Small therapeutic doses of opium have no effect 
upon the circulation, but large ones primarily slow the pulse, increase 
its force, and slightly raise arterial pressure. 

The slowing of the pulse depends upon stimulation of the pneumo- 
gastric nerves peripherally and centrically; the increase in pulse-force 



410 DRUGS 

results from the stimulation of the heart-muscle; the rise of pressure 
is due chiefly to the increased heart-action. 

After poisonous doses the pulse becomes rapid and feeble, due to 
depression of the vasomotor center and the heart, and the gradually 
increasing asphyxia. 

Respiration.— In very minute doses opium is a feeble stimulant, 
or at least not a depressant, to the function of respiration. In over- 
dose it is one of the most powerful paralyzants of the respiratory 
centers in the medulla oblongata, causing death by this action. 

Temperature.— The bodily temperature is raised slightly by 
full doses and lowered by poisonous amounts of opium. 

Tissue-waste.— Opium acts as a preventive to tissue-waste, 
decreasing the elimination of urea and other results of nitrogenous 
breakdown. 

Elimination.— If given in excess, the drug escapes from the body 
as morphine, by way of the intestine and kidneys, but most of it is 
destroyed by oxidation in the liver and tissues. Experiments made 
by Alt and Tauber show that morphine is largely eliminated by the 
stomach, and that if this viscus is frequently washed out during a 
case of poisoning, recovery is much aided, as by this means resorption 
is prevented. 

Pupils.— The myosis caused by morphine is often ascribed to 
depression of the dilator portion of the pupillary center situated in 
the medulla, but the existence of such a center is purely hypothetical, 
and it is probable that the older teaching, to the effect that the myosis 
is due to centric oculomotor stimulation, is correct. 

Stomach, Intestines, and Secretion.— Opium depresses the 
motor activity of the stomach and intestines and produces consti- 
pation. It does this by stimulating the splanchnic inhibitory fibers 
of the intestine and thereby preventing peristalsis. In very large 
doses it increases peristalsis by paralyzing these fibers. 

Opium checks every secretion in the body except that of the skin. 

Acute Poisoning.— When opium is taken by man in overdose, it 
causes drowsiness, deep sleep, full breathing, a slow, full pulse, a 
warm, dry skin, contracted pupils, and pleasant— or, more commonly 
in the Anglo-Saxon race, disagreeable— dreams or no dreams at all. 
Preceding this period there may be a brief one during which the 
individual feels self-satisfied and contented. The duration of this 
agreeable sensation lasts only a short time, and if the dose is large 
does not occur or is evanescent. It has been called the first stage, 
while the more marked symptoms just described have been grouped 
into a so-called second stage. 

During the sleep of the second stage the patient may be roused 
by shouting in his ear or by violent shaking, but sinks into slumber 
at once when not disturbed. 

Many of the symptoms resemble those of congestion of the brain. 
The face is suffused and reddened, and may be finally distinctly 



OPIUM 411 

cyanotic. The breathing may be puffing and stertorous. When the 
patient is awakened, he breathes more rapidly, and for this reason the 
duskiness of the face disappears and the normal hue returns. Death 
never occurs in the second stage of opium poisoning from the poison 
alone, but if a complicating disease is present death may take place 
at this time. 

The third or fatal stage emerges from the second by a process so 
gradual that no abrupt line of separation can be noted. The face 
becomes at first more cyanotic, then pale and livid ; the respirations, 
which have been 8 to 10 to the minute, are now only 4 to 5, and 
finally such prolonged pauses occur that all hope of another respira- 
tion is lost by the attendant. While the slow breathing is at first 
deep, it soon becomes shallow, and muscular relaxation is present 
to the greatest degree. The skin, previously dry, is wet with the 
sweat of death, the patient is so deeply narcotized that nothing 
can arouse him, and he dies from respiratory failure, although the 
heart may cease almost simultaneously from the asphyxia. The 
pupils do not dilate in the third stage, except in the relaxation of 
death. 

Treatment of Acute Poisoning.— After employing the usual 
methods resorted to for the purpose of emptying the stomach, and 
after "giving permanganate of potassium or tannic acid, preferably 
the former, as the chemical antidote, the patient should receive by 
the rectum one or more cups of black coffee, hot and concentrated. 
The heat in the liquid is useful in maintaining bodily temperature, 
and the caffeine stimulates the respiratory center and keeps the 
patient awake. Coffee should be used even before any symptoms 
come on, in order to prevent their onset if possible. If strychnine 
is at hand and the respirations are becoming very slow, -£$ to y^ 
grain (0.002-0.006) should be given hypodermically. Strychnine is 
much better than atropine as an antidote to opium, and should be 
given hypodermically in full dose, repeated frequently enough to 
keep the nervous system of the patient active and respiration intact. 
The pupil is no guide as to the action of atropine in opium poisoning, 
as the influence of these two drugs (opium and atropine) on the eye 
is not directly antagonistic. Cocaine is thought by some physicians 
to be a satisfactory physiological antidote to opium. 

Ammonia as a cardiac and respiratory stimulant may be resorted to. 

In the third stage heat should be applied to the trunk and extrem- 
ities. 

Much emphasis has been placed on keeping the patient awake, 
and it has been thought that the cause of death was the deep sleep. 
This is not so. The man must be kept awake in order that he will 
supplement the efforts of his depressed respiratory centers by volun- 
tary breathing. If he sleeps, he forgets to breathe, and sleep means 
death for this reason, and not because sleep in itself produces death. 

Besides the use of hot strong coffee, the patient may be kept 



412 DRUGS 

awake by lashing him with switches or by walking him up and down 
between two attendants. Both of these measures are reprehensible 
if anything better can be done— the first method because it covers 
the patient with cuts and bruises, the second because it may aid in 
the production of death by exhaustion. If an ordinary medical 
f aradic battery is at hand, the full force of the current may be allowed 
to come in contact with the skin from two small poles wet with salt 
water, or, better still, the dry or wire electric brush should be swept 
over the body while the negative pole is held in the hand of the patient 
or pressed against his skin. This causes the most exquisite pain in 
the normal individual, but if the brush is kept moving will not cause 
bruises or discoloration. (See Asphyxia.) Artificial respiration may 
be resorted to. 

As pointed out when discussing the elimination of opium, the 
drug is eliminated into the stomach from the bloodvessels and then 
reabsorbed. Frequent washing out of the stomach is therefore 
advisable in cases of poisoning. 




Fig. 59. — A, opium produces sleep by depressing the intellectual centers of the brain, 
and B, relieves pain by depressing the perceptive centers in the brain. 

Chronic Poisoning.— Morphine or opium when taken constantly 
generates a habit. The person — or morphine-habitue, as he is some- 
times called— depends for a comfortable existence on the drug, and 
day by day increases the dose until the most extraordinary amounts 
are taken by the stomach or by means of the hypodermic needle. 
This ability to take large doses depends upon an increased ability 
on the part of the body to oxidize the poison. A full dose given 
to an ordinary person results in the escape by the bowels of a large 
percentage of it, but if gradually increasing doses are given, no 
trace of even large doses are obtainable in the stools or urine. If 
the drug is withheld from the morphine habitue, a train of symptoms 
typifying depression or exhaustion ensues. The pulse is scarcely 
to be felt, horrible mental depression and melancholia come on, the 
miserable man or woman wrings his or her hands, and begs, screams, 
howls, or yells for morphine, only to break down and cry on being 
refused the customary dose. Diarrhea of a serous type and most 
violent in character, with cramps in the muscles, may assert itself, 
and must be controlled by astringents and camphor, and an active 
line of treatment, as far as possible free from opium. (See Diarrhea.) 



OPIUM 413 

A characteristic symptom of chronic opium-eating is the develop- 
ment of the most clever lying in previously truthful persons. In the 
same breath that the patient begs the physician to cure him, he will 
lie to obtain the drug in a surreptitious manner, and may even have 
the drug in his mouth at the moment he speaks. It will often be 
found hidden in the seams of the clothing, and the nurse must be 
absolutely reliable, above bribery, and forever on the watch lest the 
drug be obtained by smuggling. Any sudden improvement on the 
part of the patient should be placed to the credit of more morphine, 
not to professional skill. 

The well-known fact that certain races of mankind are affected 
by some drugs in quite a different manner from that exerted upon 
the white race finds an interesting confirmation in the opinion 
expressed by physicians and government officials, who have investi- 
gated the subject in India and China, that a large number of Orientals 
use opium in moderation for years without deleterious effects. They 
remain well nourished, are able to perform labor requiring severe 
physical exertion, and the death-rate among them is not higher than 
among other classes of people. 

Sometimes paregoric is taken in excess, and the writer has seen 
and treated a case in which over a pint of paregoric was taken every 
day. 

When a mother is an opium-eater, the newborn child often suffers 
from collapse on the second or third day after birth, owing to the 
lack of its customary dose of opium. 

Treatment.— The best way to decrease the use of the drug is to 
"taper off" the daily dose, and to decrease by a sixth or a fourth 
the total customary amount in each twenty-four hours. The sudden 
complete withdrawal of the drug is an unnecessarily severe measure, 
and its withdrawal in a slower manner than that named is simply 
prolonging the treatment beyond reasonable limits. 

It is essential at the beginning of the withdrawal that the liver 
and bowels be thoroughly unloaded by 5 grains of blue mass and 10 
to 20 grains of compound extract of colocynth. 

A very valuable means of treatment is the use of very full doses 
of hyoscine hypodermically. If this plan is followed, the morphine 
may be sometimes withdrawn at once. (See Hyoscine.) If the 
circulation flags, digitalis and strychnine may be given and the 
remaining symptoms treated as common-sense indicates. Cocaine 
has been unwisely used to tide over the crisis after the withdrawal 
of the morphine, and too frequently the patient passes from opium 
to the cocaine, and finally to the alcohol habit, all of which are 
equally bad. 

A method of treatment of the morphine habit which has attained 
considerable popularity is the so-called Towns' method. This method 
is also utilized in the treatment of patients addicted to cocaine and 
alcohol. It appears exceedingly rigorous, but it is claimed that even 



414 DRUGS 

debilitated and feeble patients are able to withstand it with advan- 
tage. The patient, being under absolute control as to his ability 
to obtain morphine, is given 5 compound cathartic pills and in 
addition 5 grains of blue mass. Six hours later, if these have not 
acted, a saline purge is given. After the patient has three or four 
copious movements he receives, by the mouth or by hypodermic 
injection, according to his custom in taking the drug, two-thirds to 
three-fourths of this total daily intake in three divided doses at 
half -hour intervals. Six drops of a mixture of tincture of bella- 
donna, 2 parts; fluidextract of xanthoxylin, 1 part; and fluidextract of 
hyoscyamus, 1 part, are given in a capsule at the same time as the 
morphine, cocaine, or alcohol and repeated every hour for six hours. 
At the end of six hours, the dose of this mixture is increased by 2 
drops and it is continued every subsequent hour, day and night 
continuously, throughout the treatment, increasing by 2 drops every 
six hours until 16 drops are given at a dose. If the patient shows 
very marked symptoms of the physiological action of the belladonna 
mixture the dose may be diminished, but, on the other hand, if he is 
resistant to the drug, it must be increased up to 20 drops every hour. 
Ten hours after the first dose of morphine has been received the 
patient is again given 5 compound cathartic pills and 5 grains of blue 
mass and if these doses do not act upon the bowels in six or eight 
hours a vigorous saline purge is administered. The morphine is 
used after this purgation in half the original dose, and ten hours 
later the same number of compound cathartic pills and the same 
amount of blue mass is used. After thirty-six hours have elapsed 
from the beginning of the treatment the third dose of morphine, which 
is one-fourth of the original amount, is given, and it is claimed that 
this is usually the last dose which is needful. Forty-six hours after 
the beginning of the treatment the compound cathartic pills and 
blue mass are again given, again followed by a saline, and, possibly, 
as late as the fifty-sixth hour of treatment a fourth small dose of 
morphine may be used with two ounces of castor oil. 

When alcoholism is being treated, the belladonna mixture and the 
5 compound cathartic pills and 5 grains of blue mass are given simul- 
taneously at the first dose and then repeated on the twelfth, twenty- 
fourth, and thirty-sixth hour, and castor oil is given after the forty- 
fourth hour. In cases where nervous excitement is very marked, a 
continuous hot bath is to be used as a sedative method of treatment. 
After this plan has been carried out the patient is given tonics, fresh 
air, moderate exercise and good surroundings. 

Therapeutics.— Opium is used for the relief of five great conditions, 
which will be spoken of seriatim, the minor uses of the drug being 
considered afterward. These are pain, insomnia, inflammation and 
irritation, oversecretion and systemic strain. 

Pain.— Opium is the best remedy that we possess for the relief of 
all forms of pain, except in those instances when neuralgia is present, 



OPIUM 415 

when antipyrine and its fellow-compounds exceed it in medicinal 
value because they have no marked after-effects. It is to be remem- 
bered, however, that no drug has yet been discovered which equals 
its pain-relieving power in this or any other painful affection. In 
acute or traumatic meningitis opium is of great service, either alone 
or combined with mercury in sthenic cases. In the treatment of 
renal and hepatic colic associated with spasm, and in dysmenorrhea, 
belladonna, and opium given together will relieve the spasm and 
pain, and yet so counteract each other elsewhere in the body as to 
be devoid of marked effect upon other organs. Usually in these 
severely painful affections it is best to give morphine and atropine 
hypodermically. Persons suffering from severe pain will usually 
bear larger amounts of opium than individuals without pain. 

For the relief of violent pain physicians of experience usually employ 
morphine hypodermically as the most rapid and effective means of 
giving relief. If this is not possible, the morphine should be given 
by the mouth in a little hot water with or without whisky or brandy 
added to it; or tincture of deodorized opium may be given in the same 
manner. If neither the hypodermic needle nor the draught can be 
resorted to, then the drug is best given, in the form of the tincture, 
by the rectum, being first mixed with warm starch-water. If the 
pain is chiefly in the pelvic viscera, the rectal administration of the 
drug is advisable by clyster or by suppository. 

When pain is due to violent sciatica or to muscular spasm, it is 
best relieved by injecting the morphine directly into the subcutaneous 
tissues or the muscles of the affected part. In other instances local 
pain due to superficial inflammation may be relieved by compresses 
wet with laudanum and lead-water. It is claimed that if morphine 
sulphate is given in 2 cc of a 25 per cent, solution of magnesium 
sulphate it is greatly increased in power. 

To patients who are prone to frequent attacks of pain opium must 
be given with caution, as the " opium habit" is easily produced. 

Many surgeons give | to | grain (0.008-0.015) hypodermically 
before administering ether or chloroform, because less of the latter 
drugs are needed to cause anesthesia. 

(For the use of morphine and scopolamine for the production of 
surgical anesthesia, see Scopolamine.) 

Insomnia.— Opium, while capable of producing sleep in almost 
every case in which it is given, save in those individuals who by 
reason of idiosyncrasy are made wakeful by it, is only to be used in 
those instances where the sleeplessness is due to pain. If constantly 
used for the relief of insomnia or pain, the opium habit is rapidly 
contracted, and for this reason the use of this drug should be 
alternated with chloral, cannabis, and other soporific drugs. 

In some cases chloral and morphine, when given in small doses 
in combination, will so act upon the brain as to produce sleep. Thus, 
in the following prescription, the dose of both active ingredients is 



416 DRUGS 

much smaller than would be needed if either was used alone, yet the 
result sought by their use— namely, sleep— is readily produced: 

]$ — MorphinsB sulphatis gr. ij (0.12) 

Chlorali hydrati ..." 5j (4.0) 

Syrupi fgj (30.0) 

Aquae destillatae .... fgij (60.0).— M. 

S. — Dessertspoonful (8.0) at 9 p.m., and, if needed, again at 10 or 11 o'clock. 

In the persistent insomnia of typhoid fever, croupous pneumonia 
and all acute diseases in which nervous exhaustion is due to lack of 
sleep, a hypodermic injection of morphine will sometimes produce 
most excellent results, but the proper use of cold bathing in typhoid 
fever is to be preferred for this purpose if it can be employed. (See 
Cold, Part III.) 

Inflammation and Irritation.— Opium seems to possess some 
influence over inflammation which we cannot explain, and both small 
and large doses are valuable in inflammation of serous membranes, 
such as pleuritis, meningitis, and pericarditis. In peritonitis opium 
has been thought to be useful, but grave doubts are now entertained 
as to its value. (See the article on Peritonitis in Part IV.) 

Opium allays the nervous excitement and cough following hemop- 
tysis, and the intense unrest caused by itching skin diseases, as, for 
example, the irritation of smallpox. 

Sometimes intense irritation or inflammation produces so great 
an effect upon unstriped muscular fibers as to cause spasm or paralysis, 
as in retention of urine, cystitis, or the constipation following inflam- 
mation of 4he bowels due to the ingestion of irritating foods; under 
these circumstances the employment of opium is indicated, and is 
usually very successful. In irritative coughs morphine given in syrup 
of wild-cherry bark does good in the dose of -^ to yo (0.005-0.006). 

In some cases of irritable cough due to a tickling sensation in the 
larynx, much relief can be had by inhaling the steam arising from 
a cup of boiling water in which has been placed a dram or two of 
paregoric. 

Whenever cough is excessive— that is, greater than is necessary to 
free the lungs of mucus— morphine may be given in small doses. 
If the lungs contain more rales after its use than before, its use 
must be stopped, as the increase in the number of rales indicates 
that cough is necessary to keep the bronchial tubes clear. 

In the treatment of strangury due to cystitis, and in rectal inflam- 
mation, and after operation on the pelvic organs, suppositories of the 
strength of i to J grain (0.015-0.03) of the water extract of opium 
are useful. In excessive vomiting from any cause, except it be from 
a previous dose of opium, an enema of tincture of deodorized opium 
30 minims (2.0) and starch-water 4 ounces (120.0), with 40 grains 
(2.6) of bromide of sodium, will be found of value. (See Vomiting, 
Part IV.) 

In muscular rheumatism and similar states, and in the incipient 



OPIUM 4:17 

stage of a "cold," opium in the form of Dover's powder in the dose 
of 5 to 10 grains (0.3-0.6) will often produce a cure, particularly if 
employed in combination with hot drinks and a hot foot-bath. 
Camphor can often be added to the Dover's powder with advantage. 
(See Coryza, Part IV.) 

For sprains and bruises lead-water and laudanum is one of the best 
applications. (See article on Lead.) If the skin is broken, the 
laudanum may be used alone to relieve pain, and, by its alcohol, will 
act as an antiseptic. Opium is also a useful drug in the treatment 
of internal and external burns to relieve the pain and irritation. 

Oversecretion.— In serous diarrhea, diabetes insipidus and met- 
litus, and in the treatment of oversecretion on the part of all secreting 
surfaces except the skin, opium may be used. 

Opium is said to decrease the amount of urine before decreasing 
the amount of the sugar in diabetes. However this may be, the 
employment of opium or morphine or codeine in diabetes is a valu- 
able aid to treatment. When moderate doses fail their size must be 
rapidly increased, as the effect may be obtained only by ascending 
amounts, and diabetic patients seem peculiarly immune to the 
nervous influence of this drug and its alkaloids. Morphine is, thera- 
peutically, more powerful than codeine, but crude opium is more 
powerful for good in this affection than either. None of them, 
probably > cure the disease, but so modify it as to make life bearable, 
for the sugar is decreased in many cases, and the excessive hunger, 
thirst, and nervous irritability are relieved. Itching of the skin is 
also allayed in this class of patients by its use. (See article on 
Diabetes, Part IV.) The sudden withdrawal of opium from a case 
of diabetes may precipitate diabetic coma. 

Opium should not be used to arrest an attack of mucous diarrhea 
until after the mucus which is already present in the bowel has been 
swept out of the intestinal canal by a dose of castor oil or magne- 
sium sulphate. Minute doses of -^ to -jfa grain (0.0008 to 0.0012) 
of morphine given hypodermically will sometimes check summer 
diarrhea in children at once after all undigested food has been swept 
out by castor oil. (See article on Diarrhea.) 

Morphine rather than opium is used to relieve pain because it 
does not cause so much constipation, but opium is better to check 
diarrhea. Paregoric is particularly useful in diarrhea because it 
contains a volatile oil and camphor. 

Systemic Strain.— In prolonged strain upon the system, as in 
great physical or nervous effort, or more frequently in old age to 
smooth the remaining years of life and decrease worry, opium is 
useful, but its use in young persons is most dangerous, as it is almost 
certain to produce the opium habit. In asthenic fevers opium is 
thought to be supportive, but its use is apt to cause so many other 
conditions, such as constipation, anorexia, or mental depression, that 
alcohol is much better for this purpose. In advanced phthisis it is 
27. 



418 DRUGS 

often justifiable to give sufficient opium to keep the patient free 
from pain and discomfort for the remaining hours of his life, but care 
must be taken that the dose does not interfere with the breathing 
and so hasten death. 

In heart disease, particularly of the mitral valves, the patient can 
often breathe easily only when awake, starting up when he falls 
asleep and gasping for breath. It is stated by some writers that 
morphine will relieve this state and permit sleep, but that it will not 
be of service in aortic disease. While this may be partly true, the 
drug will often give great relief in all forms of cardiac dyspnea, and 
ought always to be tried with caution. Care should be taken that 
the first dose is small, as in some instances it increases the discom- 
fort. The relief obtained is supposed to be due to cardiac stimulation 
by the drug, and this is no doubt correct, but the nervous quiet or 
sleep which is induced probably rests an exhausted heart. The 
presence of cyanosis and lividity is said to be no contraindication 
to the hypodermic use of morphine under there circumstances, pro- 
vided the dose is not unreasonably large, and provided these signs 
are purely circulatory in origin. If they are due to pulmonary edema 
or diffuse bronchitis, it is unsafe. Xot rarely in the course of pneu- 
monia and typhoid fever a state of nervous restlessness with active 
talkative delirium develops, in which the patient may die from lack 
of sleep. At such times a hypodermic dose of morphine may be 
most useful and save life. The drug should be given hypodermically 
for these purposes in the dose of about J grain (0.015). 

Opium and morphine, particularly the latter, have been freely 
given to produce quiet in patients with uremic convulsions. The 
practice is a dangerous one, and should not be resorted to as a rule, 
as the impaired state of the kidneys prevents elimination of the drug. 
In some cases of uremic dyspnea and nervous irritation it is wise to 
give it provided the liver is active and the urine free. 

Administration.— Studies upon the action of opium and its alka- 
loids show that it acts in an inhibitory manner upon gastric diges- 
tion and absorption, decreasing the amount of hydrochloric acid in 
the gastric juice. For this reason, unless there is an excess of acid 
present in the stomach, it is well not to give opium or morphine at 
meal-time, but some time after. 

Opium itself is used in the form of the powder (Opii Pubis, U. S.), 
and in granulated form (Opium Granulatum, U. S.) in the dose of 
from i to 2 grains (0.015-0.12) and deodorized opium (Opium Deodo- 
ratum, U. S.), which is deprived of its narcotine, dose J to 2 grains 
(0.03-0.12). Both these preparations should yield on assay not 
less than 12 per cent, nor more than 12.5 per cent, of morphine. Of 
the watery extract (Extractum Opii, U. S. and Extractum Opii Siccum, 
B. P.) the dose is i to | grain (0.015-0.03), } to 1 grain (0.015-0.06), 
B. P. Of the liquid preparations we have paregoric ( Tinctura Opii 
Camphorata, U. S.; Tinctura Camphoroe Composita, B, P.), dose 1 



OPIUM 419 

dram to 1 tablespoonful (4.0-16.0); B. P. dose is 30 to 60 minims 
(2.0-4.0); laudanum {Tinctura Opii, IT. S. and B. P.), dose 5 to 30 
minims (0.3-2.0), containing not less than 1.2 nor more than 1.25 
gram (B. P. 1 per cent.) of crystallizable morphine in 100 cc; the 
tincture of deodorized opium {Tinctura Opii Deodorati, U. S.), dose 
5 to 20 minims (0.3-1.3), containing not less than 1.2 nor more than 
1.25 gram of crystallizable morphine in 100 cc; Vinum Opii, some- 
times called Sydenham's laudanum, dose 5 to 30 minims (0.3-2.0); 
and Acetum Opii, ox black drop, dose 5 to 30 minims (0.3-2.0). 

As all the liquid preparations of opium in the U. S. P. are of 10 
per cent, strength, except paregoric, which is about 2 grains to the 
ounce, the dose of all of them except paregoric is identical. This 
is a fact to be particularly remembered by students. 

Under the name of Dover's powder {Pulvis Ipecacuanha et Opii, 
U. S.; Pulvis Ipecacuanha? Compositus, B. P.), a powder containing 
1 part of powdered opium, 1 part of powdered ipecac, and 8 parts of 
sugar of milk is largely used. The dose is 5 to 20 grains (0.3-1.3). 
It is more efficacious if separated into fifths and taken in divided 
doses. The tincture of ipecac and opium {Tinctura Ipecacuanha? et 
Opii) is given in the dose of 5 to 30 minims (0.3-2.0). 

The preparations of opium official in the B. P., other than those 
named, are Extractum Opii Liquidum, dose 5 to 30 minims (0.3-2.0) ; 
Pulvis Opii Compositus, composed of opium, pepper, ginger, caraway- 
fruit, and tragacanth, dose 2 to 10 grains (0.12-0.6); Tinctura Opii 
Ammoniata, dose § to 1 dram (2.0-4.0). Pihda Saponis Composita, 
B. P., is really a preparation of opium. It is sometimes necessary 
to give this drug to patients without their knowledge, and it may 
be prescribed in this way, the patient not learning from the prescrip- 
tion the nature of the medicine. The dose is 2 to 4 grains (0. 12-0.25) . 

Under the name of pantopon {Pantopium Hydrocldoridum) a 
German preparation, a soluble preparation of the combined alka- 
loids of opium is on the market for use by the mouth or hypodermic 
needle. It is claimed to be more sedative than morphine. The 
dose is i to } grain (0.01-0.015). 

Untoward Effects.— When opium is given to some individuals it 
produces for several hours marked wakefulness followed by sleep, 
and in many patients causes after its primary influence great nausea, 
and sometimes vomiting. The mental depression may be simply 
overwhelming, and the very fact of having to drag out existence is 
a curse. By far the most effective mode of preventing these very 
distressing effects of opium or its derivatives is to administer with 
this drug about T io grain of nitroglycerin. One of the chief causes, 
however, of the nausea produced by the use of opium or morphine is 
the change in the body of morphine into oxy-dimorphine, which is 
eliminated into the stomach and there reabsorbed, and then induces 
these secondary effects. It is also a fact that these symptoms can 
be largely relieved by the use of 20 grains (1.3) of bromide of potas- 



420 DRUGS 

sium, which must be taken at the same time as the opiate, and by 
employing the preparations of opium largely devoid of narcotine, 
such as the deodorized tincture or deodorized opium itself. When- 
ever possible these preparations should be used to the exclusion of 
the others. Haig is responsible for the assertion that, as opium 
frees the blood from uric acid by causing its retention in the tissues 
of the body, the pleasant effects are so produced, and that, the 
retention being cumulative, no sooner does the effect of the opiate 
pass off than the uric acid is set free in the blood, and as a result 
depression ensues. He states that if salicylates are given with the 
opium retention does not occur, and the unpleasant sequelae are 
modified or prevented. After the untoward symptoms come on 
coffee and stimulants may be used with advantage to overcome them. 
In some persons the use of opium is followed by itching of the skin 
or by the development of an erythematous rash which may go on to 
desquamation. 

Children bear opium badly, and some children are very much more 
susceptible than others to its influence. 

One-eighth grain of morphine has caused death in an adult when 
given hypodermically, probably because it entered a vein. Some- 
times the drug causes collapse, or in other cases an eruption upon 
the skin of the body. 

The use of repeated doses of morphine for several days often 
excites obstinate vomiting, due probably to the change of the drug 
into oxydimorphine or apomorphine. 

Codeine. 

(See p. 238.) 

Morphine. 

Morphina, U. S. and B. P., is the chief alkaloid of opium, but 
owing to its insolubility is rarely used, being generally given in the 
form of sulphate. 

Sulphate of morphine (Morphines Sulphas, U. S.) is given in the 
dose of | to J grain (0.008-0.03), either by the mouth or hypo- 
dermically. Besides the sulphate of morphine we have the hydro- 
chloride (Morphines Hydrochloridum, U. S. and B. P.), and the 
tartrate (Morphines Tartras, B. P.), all given in the dose of f to \ 
grain (0.008-0.03). In the U. S. Pharmacopoeia of 1870 a solution 
of morphine was official, called Liquor Morphines Sulphatis (B. P.), 
dose 1 to 2 drams (4.0-8.0) ; but it is no longer official and should 
not be called for. Magendie's solution of morphine is sixteen times 
as strong as the liquor just named (16 grains to the ounce), and is 
also not official. The words "Liquor Morphinse Sulphatis" may 
cause Magendie's solution to be dispensed particularly in New 
York State, and care should be taken that poisoning does not result. 



OVARIAN EXTRACT 421 

Pulvis Morphines Compositus, or Tully's powder, is given in the dose 
of 10 grains (0.06). Ten grains contain sulphate of morphine about 
i grain (0.6), camphor 3 grains (0.19), liquorice 3| grains (0.2), and 
precipitated calcium carbonate 3 J grains (0.2). It is used to check 
forming colds and as a nervous sedative. Troches of morphine and 
ipecac (Trochisci Morphines et Ipecacuanha) are given one or two 
at a time for irritation of the pharynx. 

The following additional preparations of morphine are official in 
the B. P. : Liquor Morphines Hydrochloridi and Liquor Morphince 
Tartratis, dose 10 to 60 minims (0.6-4.0); Tinctura Chloroformi et 
Morphine Composita, dose 5 to 15 minims (0.3-1.0); Suppositoria 
Morphince, each suppository containing J grain (0.015) of morphine; 
Trochiscus Morphince and Trochiscus Morphince et Ipecacuanha, each 
lozenge containing -^ grain (0.002) of morphine, dose 1 to 4. Liquor 
Morphince Acetatis is given in 10- to 60-minim (0.6-4.0) doses. 
Injectio Morphince Hypodermica, B. P., contains § grain (0.03) of the 
tartrate of morphine in each 22 minims (1.4) of water. Its dose is 1 
to 10 minims (0.05-0.6). 

Incompatibles.— Morphine is incompatible with potassium perman- 
ganate and with tannic or gallic acid or solutions containing them; 
with alkalies, such as potassium, sodium, and ammonium salts, but 
with chloride of ammonium it is not incompatible. With tincture 
of chloride of iron it forms a deep red color (meconic acid). 

ORTHOFORM. 

Orthoform, which is the methyl ester of para-aminometaoxy- 
benzoic acid, has been supplanted by "orthoform new," which is 
metamino-para-oxybenzoic acid and the latter is a colorless, bulky, 
odorless, and tasteless powder which is quite soluble in hot water. 
It is used as a local anesthetic and antiseptic dressing for small 
wounds and burns, and is said to be non-toxic, but this is an error. 
It may be applied in powder or ointment. The latter is usually of 
the strength of 2 drams to the ounce of lanolin (8.0-30.0). It may 
be given by the stomach in cases of epigastric pain to determine 
its source. In cases of gastric ulcer it may relieve the pain, but if the 
pain be due to gall-stones it will fail. The dose is 2 to 5 grains 
(0.12-0.3), in pill or capsule, three times a day on an empty stomach. 

OVARIAN EXTRACT. 

The ovarian gland, in the form of the dried gland substance or 
in that of an extract made from it, has been used for relief of the 
nervous and nutritional disturbances of the menopause, whether 
they be the result of age or of operative removal of these bodies. It 
is said to be the most efficacious in those instances in which the 
ovaries have been removed from young women. As the use of the 



422 DRUGS 

ovarian extract in medicinal doses seems to be harmless, it may be 
given for a long time without danger. The beginning dose should 
be 2 to 4 grains (0.12-0.25) a day, and this be gradually increased 
until some effect is produced or it proves useless. The best method 
of giving it is in compressed tablet or in capsule. Professional 
opinion as to its value is much divided. (See Corpus Luteum.) 



OX-GALL. 

Ox-gall (Extractum Felis Bovis, U. S.) is, as its name implies, dried 
ox bile, derived from the gall-bladder of the common ox (Bos taurus). 
It is used in medicine for the purpose of relieving certain forms of 
indigestion which result from deficient secretion of bile or which 
occur in persons who digest fats with difficulty. In full doses it is 
apt to cause some looseness of the bowels, and it may be given with 
the object of producing this condition. When it is used, the fact 
should be remembered that bile prevents the gastric juice from 
acting upon proteid or albuminous substances, shrivelling them up, 
and in addition so alters the gastric liquids as to decrease their 
digestive power. We know, therefore, that this drug must be 
administered some hours after meals, as a rule, or, in other words, 
when gastric digestion is ended and intestinal activity is beginning.- 
The dose of ox-gall is 5 to 15 grains (0.3-1.0). Purified ox-gall; 
Fel Bovinum Purificatum, B. P.) is given in the same dose as U. S. 
P. preparation. 

OXYGEN. 

The gas oxygen is now widely used in medical and surgical practice 
in two ways, as follows : By inhalation of the gas itself from a cylin- 
der in which it is compressed until 40 gallons occupy a very small 
space; and by the use of the dioxide or peroxide of hydrogen, which 
is applied locally to diseased surfaces. (See Hydrogen Peroxide.) 

Inhalations of oxygen are useful in the second and third stages 
of pneumonia where the patient seems to be suffering from deficient 
aeration of the blood and associated heart-distention. They are also 
of value in advanced bronchitis, particularly that of old persons, and 
for the resuscitation of individuals asphyxiated by coal-gas (Hare 
and Martin). In phthisis and other exhausting diseases oxygen will 
allay dyspnea and oppression. Oxygen inhalations are also of 
service in the treatment of anemia in all its forms and give relief even 
in pernicious anemia and in leukemia. Often a mixture of oxygen 
gas 60 parts and nitrous oxide gas 40 parts is used as a stimulant 
inhalation and nervous sedative. 

The clinical results which have so far been obtained from the 
administration of ether and chloroform vapor when combined with 



OXYGEN 423 

oxygen gas seem to prove beyond all doubt that the oxygen decreases 
the danger of the anesthetic and to a large extent obviates the 
difficulties which attend the administration of these drugs, and most 
of the untoward effects which result from their use. Thus, when 
oxygen is given with ether, vomiting is less frequently met with, 
excessive pallor is rarely seen, and post-operative depression seems 
to be largely avoided. 

As a general rule, however, it has been the custom of physicians 
and surgeons who have employed oxygen gas in combination with 
ether or chloroform, to place the anesthetic in a wash-bottle and 
then to allow the oxygen gas to pass through it in such a way that 
the patient received in the inhaler a mixture of anesthetic vapor and 
oxygen, the mixture resulting from the passage of the oxygen gas 
through the liquid anesthetic in the bottle. An evident disadvant- 
age of this arrangement is that the quantity of anesthetic which is 
volatilized can only be in direct proportion to the volume of oxygen 
gas which is forced through the wash-bottle, and therefore with 
every increase in the quantity of vapor which the patient receives 
he must also receive an increased quantity of oxygen. It has been 
claimed too, by those who have employed the ether and oxygen 
combination most frequently, that in a large proportion of cases a 
greater length of time is required for the anesthetizing of the patient, 
and that in some cases it seems almost impossible to get the patient 
under the direct influence of the drug. This difficulty lies in the 
fact that as soon as a large quantity of oxygen gas is used to convey 
much of the anesthetic vapor to the lungs, the patient rapidly passes 
into a condition which is called by physiologists apnea. The respi- 
ratory center is no longer irritated by the normal proportions of 
carbonic acid in the blood, and therefore sends out feeble respiratory 
impulses; and as the patient does not breathe so rapidly or so deeply 
as before, the result is that very small quantities of the anesthetic 
are taken into the body. 

The tube which leads off from the oxygen tank should be placed 
under the edge of the inhaler and the gas given as desired. 

The writer cannot condemn too strongly the method of employ- 
ing chloroform vapor and oxygen by passing the oxygen directly 
through the chloroform without the free administration of air in 
addition for, after all, air is what we are intended to breathe, and 
not oxygen gas alone, although it may be advantageous at times 
to add an increased quantity of oxygen to the air. 

Still more severe condemnation should be directed toward the 
attachment which is placed on some of the Junker inhalers, and 
which consists of a small rubber bag which, instead of acting as a 
reservoir of fresh anesthetic vapor and oxygen, is inflated and col- 
lapsed by the expiration and the inspiration of the patient, who does 
not receive even fresh oxygen and anesthetic vapor, much less fresh 
air, but, on the contrary, inhales again and again. air, oxygen, and 



424 DRUGS ] 

vapor which are loaded with the impurities of frequent expiratory 
efforts. 

(For the directions for using oxygen with nitrous oxide as an 
anesthetic see the article on Nitrous Oxide.) 

PANCREATIN AND PANCREATIC EXTRACTS. 

Under these names a number of firms now sell an extract from the 
pancreatic gland or juice of the hog or ox and the U. S. P. recognizes 
such a product under the name of Pancreatinum. Pancreatinum 
should convert 25 times its own weight of starch into substances 
soluble in water (U. S. P.). It contains, or should contain, the four 
pancreatic ferments— trypsin, which digests proteins (meat, eggs, 
etc.); steapsin, which splits up and emulsifies the fats; amylopsin, 
which has diastatic power (that is, converts starch into sugar), and 
finally a milk-curdling ferment. 

Pancreatin may be made by the physician in the following manner : 
Take the pancreas of a pig which has been killed about six hours 
after a full meal, the organ being therefore active, and, after chopping 
it finely, add to it four times its weight of dilute alcohol and allow 
it to stand for twelve hours. Decant or filter off the alcohol, and 
give the filtrate in the dose of 1 to 2 drams (4.0-8.0). Or, better 
still, as follows: Wash and chop finely a fresh pancreas, and allow 
the gland to soak in alcohol (absolute) twenty-four to forty-eight 
hours. Then squeeze out the alcohol and add to the gland ten 
times its weight of glycerin. The mixture must stand forty-eight 
hours and then be filtered, and may be used in doses of 30 minims 
(2.0) to each glass of milk. (For the use of pancreatin in artificial 
digestion see the article on Peptonized Foods in Part III.) 

Pancreatin, as prepared for the market, is a dry powder, given in 
the dose of 2 to 20 grains (0.12-1.3) after meals or during them. 

Pancreatin should usually be prescribed with bicarbonate of sodium 
to aid it in its digestive action. It is indicated in all cases of lienteric 
diarrhea and in many cases of deficient digestion. Pancreatin, or the 
powdered pancreas, may also be freely used in those cases of diabetes 
mellitus in which the disease depends upon a lesion of the pancreatic 
gland, as carcinoma or atrophy from other cause. 

Some doubt has been cast upon the usefulness of the employment 
of pancreatin in foods unless this ferment is allowed to act upon 
the aliment before it is swallowed by the patient, on the ground that 
pancreatin is destroyed and rendered inert in the presence of the acid 
which it meets in the stomach. This objection is not a valid one, 
because food remains in the stomach for from fifteen minutes to half 
an hour, before enough gastric juice is secreted to interfere with the 
pancreatic action. It is during this preliminary period that the work 
of the pancreatin is accomplished. 

Pancreatized or peptonized foods should not be employed unless 



PARALDEHYDE 425 

really needed, nor continued for any length of time, as digestion is 
finally impaired by torpor of the glands arising from disuse. 

The B. P. recognizes a solution (Liquor Pancreatis) ; dose 1 to 2 
drams (4.0-8.0). 

The dose of pancreatin is from 2 to 20 grains (0.12-1.3). 

PAPAIN, PAPAYOTIN, AND PAPOID. 

Papain, papayotin, and papoid are names given to a digestive 
ferment derived from the juice of Carica papaya. This ferment 
possesses the power of changing proteins into peptones in the pres- 
ence of an acid or an alkali, or even in a neutral mixture, thereby 
differing from pepsin and pancreatin. This power would be of 
great value, since the drug would then be useful in all forms of 
dyspepsia, were it not that careful experimentation renders it doubt- 
ful whether papain, papayotin, or papoid can really supplant either 
of the animal ferments named above. The dose of all these products 
is from 1 to 8 grains (0.06-0.5) given in solution, or better in pill. 
The plant itself, taken internally, has the reputation of being capable 
of causing abortion. 

PARALDEHYDE. 

Paraldehydum, U. S. and B. P., is a form of aldehyde used as a 
soporific and nervous sedative, and is a clear, colorless liquid with 
an ethereal odor and a burning, followed by a cool taste. It should 
be kept in dark, well-stoppered bottles in a cool place. Paraldehyde 
is readily soluble in alcohol, moderately so in cold water, less so in 
hot water. It possesses the great disadvantages of being necessarily 
given in large dose and of having a disagreeable taste and odor. 
It is also prone to disorder the stomach. Paraldehyde kills by respi- 
ratory failure when taken in overdose, but is not so depressant to 
the heart as is chloral, and it is not to be classed as a dangerous 
drug. Clouster records a case which received 2 ounces (60.0) by 
accident without grave results. The drug soon loses its power as a 
soporific. As it is speedily absorbed and acts promptly, it ought 
to be taken after the patient is in bed. The dose is 20 minims to 
1 dram (1.3-4.0) in capsule, or, better still, it may be used, after 
the formula of Yvon, as follows: 

I$— Paraldehydi Sijss (10.0) 

Alcoholis (90 per cent.) f 5iss (45.0) 

Tincturse vanillae f 5ss (2.0) 

Aquse destillatse f 5 j (30.0) 

Syrupi q. s. ad fSiv (120.0).— M. 

S. — A dessertspoonful (8.0) every half-hour until sleep is obtained. 

Another formula is as follows: 

I$— Paraldehydi 5ij (8.0) 

Olei amygdalse amarse (sine acid, hydrocyanic) . Tftiij (0 2) 

Syrupi f 5 j (30.0) 

Fluidextracti glycyrrhizae f 3ij (8.0) 

Aquse destillatae q. s. ad fSiv (120.0).— M. 

S.— Half to one dram (2.0-4.0) as a dose. 



426 DRUGS 

PARATHYROID GLAND. 

Parathyroid gland is used to relieve symptoms induced by the 
removal or damage of the patient's glands in thyroidectomy and for 
the relief of tetany, paralysis agitans, eclampsia and chorea. It is 
marketed in tablets containing one-tenth of a grain equal to three- 
fifths of a grain of fresh gland. The dose is usually one or two 
tablets a day. 

PAREIRA. 

Pareira (Pareim Radix, B. P.) is the root of Chondodendron tomen- 
tosum, a plant of Peru and Brazil, and is used as a diuretic of an 
alterative or stimulant character and for the relief of chronic inflam- 
mations of the genito-urinary tract in general, such as pyelitis, 
cystitis of a subacute type, and similar pathological states. The dose 
of the unofficial infusion is a wineglassful (30.0), and the fluidextract 
(Fluidextractum Pareim) is given in the dose of a teaspoonful (4.0) 
three times a day. The B. P. preparation of this drug is Extr actum 
Pareim Liquidum, dose 1 to 2 drams (4.0-8.0). 

PEPO. 

Pepo (Cucurbita pepo), U. S., pumpkin-seed, the seed of the ordin- 
ary domestic pumpkin, is a useful and efficient vermifuge for the 
tapeworm. The seeds are not only efficient, but are harmless to the 
host of the worm. The outer coverings of the seeds should be 
removed, and the remaining part rubbed up into an emulsion with 
water or into an electuary with sugar, the dose of the seed being 2 
ounces (60.0). This mass should be taken on an empty stomach, and 
followed in from one to two hours by an active purge. 

PEPPER. 

Piper, U. S., or black pepper {Piper Nigrum, B. P.), is the unripe 
fruit of Piper nigrum, a vine of India, Java, Borneo, and Siam. It 
contains a basic principle, piperine, which is official. 

Therapeutics.— Black pepper may be used externally as a counter- 
irritant or internally as a carminative and stimulant to the alimentary 
canal. It may also be used in all cases of atony of the mucous mem- 
branes of the genito-urinary system, but is contraindicated whenever 
acute inflammation is present, as in acute gonorrhea. It may be 
used with marked relief in the treatment of intestinal flatulence. 

The oleoresin of pepper (Oleoresina Piperis, U. S.) is given in the 
dose of | to 2 minims (0.015-0.12) in laxative pills, to prevent griping. 

A confection (Confectio Piperis) is official in the B. P., given in the 
dose of 1 to 2 drams (4.0-8.0). 

PEPPERMINT. 

Mentha Piperita, U. S., is official in the form of the dried leaves 
and tops of Mentha piperita. It has an aromatic odor and taste and 



PEPPERMINT 427 

contains an oil. Locally applied, the oil acts as an irritant and 
local anesthetic. From this oil is obtained menthol, a camphoraceous 
substance of a hot, burning taste, possessing marked power as a local 
anesthetic. (See Menthol, below.) 

Therapeutics.— Peppermint is used very largely as a domestic 
remedy for flatulence and infantile colic. Sometimes the oil is added 
to purgative pills to prevent griping, and it may be employed to 
disguise the taste of any medicines which are disagreeable to take. 
In this respect it is used as are all the volatile oils. In the colic of 
children of six months to a year of age, when it is unusually severe 
and associated with nervous symptoms, the following will be found 
of value: 

3 — Chlorali hydrati gr. xvj (1.0) 

Potassii bromidi gr. xxxij (2.0) 

Aquae menthse piperitae f oij (60.0). — M. 

S. — Teaspoonful (4.0) in a little warm water every four hours. 

When used in the treatment of neuralgia, oil of peppermint should 
be placed on a piece of linen or muslin rag and applied over the 
affected spot. Care must be taken that it does not blister the skin. 
If, after its removal, the burning is too severe to be borne, a little 
cosmoline or olive oil should be applied. Oil of peppermint is 
sometimes placed on cotton and inserted into dental cavities for 
toothache. 

It is to be remembered that the more menthol is present in the oil 
the more active will it be as an anesthetic, and that the Chinese oil 
contains more menthol than the American oil. 

Administration.— Peppermint is used in the form of the oil {Oleum 
Mentha Piperita, U. S. and B. P.), dose 1 to 4 minims (0.06-0.25); 
the spirit (Spiritus Menthce Piperita, U. S. and B. P.), dose 10 to 
30 minims (0.6-2.0); the water (Aqua Mentha Piperita, U. S. and 
B. P.), dose 1 to 2 drams (4.0-8.0); and, finally, as the troches 
(Trcchisci Mentha Piperita), to be held in the mouth in indefinite 
number. 

Menthol. 

Menthol, U. S. and B. P., or mint stearopten, or, as it is called, 
mint camphor, is derived chiefly from the essential oil of pepper- 
mint. It occurs in colorless prismatic crystals with a strong odor 
of peppermint. Upon it rests much, if not all, of the therapeutic 
activity of peppermint. Menthol is slightly soluble in water, very 
soluble in alcohol, ether, and in oils. 

Menthol has been used in the vomiting of pregnancy with great 
advantage in hourly doses of a teaspoonful of the following: 

1^ — Mentholis gr. xv (1.0) 

Spiritus frumenti f5vj (24.0) 

Syrupi f 5j (30.0) 

Menthol has also been used as a carminative and in gastralgia in 
the dose of from 1 to 2 grains (0.06-0.12) three times a day in pill 



428 



DRUGS 



or in alcoholic solution. It is contraindicated in acute inflammation 
of the gastric mucous membrane. As menthol exercises a local anes- 
thetic effect on the skin as well as on mucous membranes, it is used 
externally over the course of neuralgic nerves and for migraine by 
means of menthol pencils. 

Menthol when applied to the mucous membrane of the throat or 
nose causes a contraction of the local bloodvessels, which is not 
followed by the excessive dilatation produced by cocaine. In acute 

coryza its local application to the 
mucous membrane by a spray or 
dropper is often a source of great 
relief in a solution of about 1 grain 
(0.06) to the ounce (30.0) of water, 
or 3 grains (0.2) of menthol in \ 
ounce (16.0) of albolene. (See 
Coryza, Part IV.) 

Another very useful method of 
applying menthol is by means of a 
simple inhaler consisting of a small 
glass tube of about one-quarter of 
an inch in diameter and two and 
a half inches in length. Both ends 
are closed by a piece of gauze and 
two perforated corks, the menthol 
being placed in between. The air 
is now drawn through this tube, 
and, being heavily loaded with the 
fumes, clears the nares and relieves 
the stuffiness. It is not to be only 
smelled, but also inhaled. Care 
should be taken that the crystals 
are not allowed to enter the nos- 
trils, as they are almost cauterant in 
power. Sometimes where great ex- 
coriation of the alse of the nose exists, the too persistent use of the 
menthol may produce small herpetic spots about the nostrils. When 
menthol is inhaled for a long time or swallowed in any quantity it 
is apt to produce severe congestive headache. 

Still another method is by the use of a nebulizer. (See Fig. 60; 
also article on Inhalations, Part III.) The following mixture is 
placed in the glass jar, and the air being driven through the tube a 
vapor of the drugs is given off which is a valuable sedative to the 
entire respiratory tract. 

3— Chloretone gr. ij (0.12) 

Mentholis gr. xx (1.3) 

Camphorae gr. xx (1.3) 

Olei cinnamomi TUij (0.1) 

Petrolati liquid! f5j (30.0).— M. 

S. — Use in a vaporizer every three hours for a period of about ten minutes. Often 
it is well to use this formula in half strength. 




Fig. 60.— Nebulizer. The small 
pump on the right side forces air 
through the black tube in the glass 
jar. This air escapes from an aper- 
ture in the side of the tube and draws 
up the medicated liquid, which is then 
driven forcibly against the side of the 
glass. The finely comminuted fluid 
then passes as a vapor through the 
exit tube. 



PERMANGANATE OF POTASSIUM 429 

Sometimes menthol in 10 per cent, alcoholic solution is dropped on 

the cone with which ether is given, to diminish the irritation caused 

by that drug when it is inhaled. 

Menthol vapor is also useful in spasmodic croup. (See Part IV.) 

Emplastrum Menthol, B. P., is used as a mild local irritant and 

anesthetic. 

PEPSIN. 

Pepsinum, U. S. and B. P., is the digestive ferment of the gastric 
juice. That sold in the shops is generally derived from the pig, 
and is prepared by manufacturers in many ways. Much of the 
pepsin of the market contains more peptone than pepsin, and much 
mucus and albumin. Used with hydrochloric acid in weak solution, 
pepsin carries out the digestive action of the stomach. Pepsin 
containing peptone has the peculiar musty smell of peptone, and if 
the peptone is in excess will absorb moisture and become sticky on 
exposure to the air. 

According to the U. S. P. official pepsin must have the power to 
digest three thousand times its weight of albumin. 

Therapeutics.— Pepsin is a much over-rated remedy for indigestion, 
which in many cases is due to hepatic disorder or to actual disease of 
the stomach which it cannot relieve. Pancreatin will nearly always 
be found more serviceable, and should be given either during or 
one or two hours after meals. Pepsin should be used immediately 
after the food is taken or with it. Hydrochloric acid should always 
be given with pepsin to aid its action, and because it converts the 
pepsinogen in the gastric tubules into pepsin. Liquor Pepsini is 
given in the dose of 2 drams (8.0). Pure pepsin should be given in 
5- to 15-grain (0.3-1.0) doses. A glycerite (Glycerinum Pepsinum) 
is official in the B. P. 

Very useful and readily taken liquid preparations are pepsin 
essence and cordial, which are given in the dose of 1 to 2 drams 
(4.0-8.0) after meals. A nutritious article of diet can be made by 
adding one teaspoonful of either of these liquids to a half-pint of 
warm milk, and allowing it to cool, thereby forming "curds and 
whey" through the action of the milk-curdling ferment. (See Part 
III.) 

PERMANGANATE OF POTASSIUM. 

Potassii Permanganas, IT. S. and B. P., is a salt of a dark purplish- 
red color, appearing in small crystals and readily soluble in water. 
In the presence of moisture it rapidly gives up the oxygen which it 
contains and becomes the dioxide of manganese. 

By reason of its oxidizing power the permanganate of potassium 
is useful as an antiseptic and deodorant. It should not be employed 
as a disinfectant for filth, because its action is too fleeting, but in 
saturated solution, followed by oxalic acid solution, it proves itself 



430 DRUGS 

one of the best disinfectants for the hands in surgical practice. 
(See Antisepsis and Disinfection.) 

Permanganate of potassium is given in the same dose for amenor- 
rhea as the dioxide of manganese, but is much less efficacious. It 
is also very apt to irritate the stomach. 

The permanganate is thought to be useful in dyspepsia, flatulence, 
lithemia, and obesity, and in the first two states is often of service, 
being a destroyer of the abnormal products by oxidation. Owing to 
this oxidizing power, it has been asserted, by Weir Mitchell and 
Reichert, to be the most efficient antidote to snake venom if placed 
in the wound before the poison is absorbed. It should also be 
injected hypodermically all about the seat of the bite. Perman- 
ganate of potassium is the best chemical antidote in poisoning by 
morphine and in that caused by many other vegetable alkaloids. 
It is also a good chemical antidote in phosphorus poisoning. In 
large doses it is efficient in cholera. (See Cholera.) Owing to its 
rapid evolution of oxygen it acts as an antiseptic, and may be used 
to wash wounds, ulcers, and sores, and as a lotion in the form of a 
gargle or on a swab in the sore-throat of diphtheria and scarlet fever. 
The solution used should be from 2 to 6 grains (1.3-4.0) to the pint 
(480 cc); the former is used on mucous membranes, the latter 
for sores and wounds. In fetid rhinitis and otitis media perman- 
ganate solution is useful as a wash in the proportion of 1 grain (0.06) 
to the ounce (30.0). When given in solution permanganate of 
potassium should be dissolved in distilled water, and it should never 
be mixed in a mortar with any organic matter, as it will explode. A 
solution (Liquor Potassii Permanganatis) is official in the B. P. 

PETROLATUM. 

Under the name of Petrolatum, U. S., or soft petrolatum, or 
Unguentum Petrolei, is sold a semisolid substance derived from cer- 
tain kinds of petroleum, and sometimes called cosmoline or vaseline. 

Owing to its soothing powers and non-rancidity, it is used as an 
emollient dressing in sores and skin affections. It has no value 
except as a protective. It is not absorbed, although assertions 
to the contrary have been made. 

Petrolatum is a useful ointment base for medicaments for the 
skin. Under the name of fluid or liquid petrolatum (Petrolatum 
Liquidum, U. S.) a fluid form is sold, which is much used in the 
form of a spray in the treatment of rhinitis and after irritant appli- 
cations to the nasal cavities. Liquid petrolatum in its heavy form 
is useful as a laxative in the dose of 1 to 2 tablespoonfuls (15.0-30.0) 
at night, or a tablespoonful (15.0) three times a day. 

Petrolatum Album (U. S.), or white petrolatum, is a purer product, 
being devoid of coloring matters. 



PHENOL 431 

PHENOL (CARBOLIC ACID). 

Phenol, U. S., and Acidum Carbolicum, B. P., is also known as 
phenylic alcohol and phenic acid. Not only is it an acid, but in 
addition it is an alcohol of the peculiar group known as the phenols, 
which are derived from coal-tar by a process of distillation. Its 
acidity is, however, very feeble. The official phenol should assay 
not less than 96 per cent, of absolute phenol. 

Phenol is sold in several grades, No. 1 being the purest. Both 
Nos. 1 and 2 are crystalline, while Nos. 3, 4, 5 are impure because 
of the presence of cresylic acid and other foreign substances. Only 
No. 1 should be ordered when phenol is to be given by the mouth. 

Phenol has a characteristic odor, and varies in color according to 
its method of preparation and purity. It is soluble in 15 parts of 
water, but it is liquefied by the addition of 8 per cent, of water. 
Phenol should be kept in dark amber-colored, well-stoppered bottles. 

If the crystals be exposed to the air, they undergo liquefaction, 
and in consequence the purest phenol is usually prescribed in minim 
doses rather than in grains. It is soluble in alcohol, ether, chloro- 
form, glycerin, and most oils. It unites with alkaline bases to 
form salts, carbolates; but these are readily decomposed, even by 
the feeblest acids, such as carbonic acid. 

Physiological Action.— Locally applied to the skin, phenol produces 
at first a burning sensation, accompanied by a diffuse reddening of 
the surface. If the solution be strong, the part at once becomes 
temporarily painful, then bleached and numb, so that tactile sensi- 
bility is destroyed. Applied to mucous membranes, it causes similar 
changes, but to a more marked degree, and may even act as a mod- 
erately severe caustic of a superficial type. Owing to the coagula- 
tion of albumin produced when it is applied, it cannot cauterize 
the tissues very deeply. 

Nervous System.— Phenol acts as a depressant and paralyzant 
to the peripheral sensory nerves when locally applied. 

Upon the higher centers in the brain the acid in toxic dose pro- 
duces a condition of depression and stupor. 

The convulsions which sometimes occur after toxic doses have 
been taken are spinal in origin, as they occur after section of the 
spinal cord. The motor nerves escape almost untouched, as do also 
the muscles. Convulsions rarely develop in man. 

Circulation.— Upon the circulation in the higher animals the 
drug exercises a distinct depressant influence, stopping the heart in 
diastole in lethal dose, and paralyzing the vasomotor center even 
before the cardiac muscle is affected. These changes follow only 
lethal doses. Small medicinal doses have no effect of any moment 
upon the circulation. 

Respiration.— After large doses the breathing becomes more 
rapid and full. These changes, according to Salkowski and others 



432 DRUGS 

are due to stimulation of the respiratory centers and the peripheral 
vagi. Lethal doses almost invarialy kill by failure of respiration 
due to depression of the respiratory centers. 

Temperature.— Phenol acts as a feeble depressant to normal 
bodily temperature even when given in medicinal dose, and also 
decreases the bodily heat in fever. It lowers fever by diminishing 
heat-production and increasing heat-dissipation. This antipyretic 
power is hardly sufficient to permit of its use in disease for this 
purpose. 

Kidneys and Elimination.— When phenol is given in overdose, 
the kidneys may become so irritated that total urinary suppression 
may occur. When taken in large quantity, it causes the urine to 
become brownish-black. This discoloration is due to an educt of 
phenol which is not yet isolated, perhaps hydrochinon. Phenol is 
eliminated in the urine as phenol-sulphonate of sodium and potas- 
sium and as glycouronic acid and hydrochinon. Part of it is burnt 
up in the body. 

It is to be distinctly understood that the dark urine of phenol 
poisoning is not due to the presence of blood or of any of its educt s. 

Poisoning, Prolonged and Acute.— As the changes produced in the 
tissues of the body by acute and subacute poisoning by phenol are 
in many respects identical, they may be considered together. 

Phenol is one of the most deadly and rapidly acting poisons known, 
although this fact does not seem to be generally recognized. If 
a large lethal dose be swallowed by a man, he may drop dead from 
its effects before he can go more than a few feet from the spot where 
he stood when drinking the drug, or he may live a few hours. In 
cases where death has occurred suddenly from taking this acid 
the direct cause has been failure of respiration. If the patient does 
not die at once, all the evidences of gastro-enteritis come on. Violent 
vomiting and purging may ensue, and burning pain in the entire 
abdomen is a prominent symptom. The skin is wet with sweat, 
the face pinched and anxious. Collapse, with a thready, impercept- 
ible pulse and extreme dyspnea, may be present. The mouth and 
lips may not smell of the drug, but the mucous membrane will be 
seen to be corrugated and stained black if impure acid has been 
taken, or be whitish if the pure drug has been used. The eschar on 
the mucous membrane is a peculiar one, and is pathognomonic of 
the poison, having a white center surrounded by a reddened and 
inflamed zone, the center sometimes becoming dark brown or black. 
The postmortem will show these spots in the esophagus and stomach, 
and even in the intestines. All the internal organs, as the brain, 
kidneys, liver, and spleen, will be found filled with dark grumous 
blood, and on opening the body the odor of the acid will be perceived. 
A peculiar croupous exudate is sometimes found in the bronchial 
tubes, and fatty degeneration of a more or less widespread type often 
follows phenol poisoning. Langerhans has noted that in some of 



PLATE I 





PHENOL GANGRENE. 

Appearance of a finger four weeks after the appli- 
cation for twenty-four hours of a dilute solution of 
phenol. The finger was wrapped in cloths which were 
saturated with the carbolic solution not stronger than 
five per cent. Amputation necessary. Inflammatory 
process at the base of the finger shown by the reddened 
tissues. (Harrington's case. ) 



PHENOL 433 

these cases evidences of croupous pneumonia exist. A very common 
symptom is hoarseness of the voice due to an effect on the larynx 
after the drug is absorbed, and not from its local influence. 

A large number of cases are on record in which subacute phenol 
poisoning has been produced by its absorption from surgical dressings. 
The earliest signs of such an accident are the darkened, smoky hue of 
the urine and slight nervous unrest or cerebral disturbance. Very 
often pain in the lumbar region indicates kidney irritation. The 
dressings should be, of course, at once removed. 

Treatment of Poisoning.— The chemical antidotes to phenol 
are generally considered to be any non-poisonous soluble sulphate 
such as Epsom or Glauber's salt, which are supposed to form insoluble 
sulphocarbolates, the latter being preferable to other soluble sul- 
phates in that they also act as purgatives if freely used. Sollman 
and others have recently asserted, as the result of an experimental 
investigation, that the sulphates are useless, but there seems to be 
strong evidence that these soluble sulphates are of value in some 
instances at least. In those instances in which the symptoms are 
subacute, the intravenous injection of sodium sulphate may do much 
good because the acid combines with the soluble sulphate and so is 
rendered harmless. The further treatment consists in hot appli- 
cations to the extremities, the hypodermic injection of cardiac and 
respiratory stimulants, such as digitalis and strychnine, intravenous 
injection of "normal saline, and the use of morphine to relieve pain. 
The stomach-pump should be used if possible. 

When 'phenol has been spilled on the hands, its effect can be over- 
come if the hands are immersed at once in absolute alcohol. There is 
no satisfactory explanation of this extraordinary effect. Alcohol is 
useless as an antidote when phenol has been swallowed. 

Therapeutics.— Internally phenol is little used, but, nevertheless, 
has a very favorable effect in certain states. In nervous vomiting or 
in that due to gastric irritation the drug does good in J to 2 minims 
(0.03-0.12) doses by depressing the sensory nerves in the stomach. 

In diarrhea depending upon fermentation from 2 to 4 minims 
(0.1-0.25) of phenol do great good, particularly if combined with 10 
to 20 grains (0.6-1.3) of bismuth administered in powder or capsule. 

In gangrene and tuberculosis of the lung a spray of phenol in water 
in the strength of 5 to 15 minims (0.3-1.0) to the ounce (30.0) may 
do some good, and at least control the cough and relieve the irritation 
and tickling in the throat. 1 (See Part III, Inhalations.) Creosote 
is, however, generally preferred in these conditions at the present 
time. 

In diphtheria, ulcerated sore-throat, and even in ordinary stomatitis, 
phenol will be found of value when used in a spray or mouth-wash 
in the proportion of 1 part to 75 parts of water; and in ordinary sore- 

1 The spray must be a very fine one, or it will not carry the drug far enough down 
into the lungs to be efficacious. 
28 



434 DRUGS 

throat or that due to sepsis, in the strength of 1 part to 100 of water 
it will be found, when applied on a swab or by a gargle, to relieve 
the pain and inflammation. By means of a stick it may be applied 
pure to the spots in aphthous stomatitis. In the treatment of burns 
phenolized sweet oil in the proportion of 1 dram (4.0) of the drug to 
each 6 ounces (180.0) makes one of the best dressings that can be 
used. By means of the local anesthesia produced by the drug, 
minor operations, such as eversion of an ingrowing toe-nail or opening 
a felon, may be performed by applying the pure drug by means of 
a brush to the line of the incision. Phenol may be used as a lotion 
in the itching of jaundice in the proportion of 10 grains (0.6) of the 
drug to 2 drams (8.0) of glycerin and 2 drams (8.0) of water, or, 
better still, 4 drams (16.0) of sweet oil. 

In the form of an ointment phenol may be used in the strength of 
10 minims to the ounce (0.6-30.0) of simple cerate, particularly in 
cases of subacute eczema where there is a great amount of weeping. 
In cases of eczema with much itching, and in pruritus and lichen 
planus, the following ointment is useful: 

1$ — Mentholis gr. v (0.3) 

Phenolis gr. x (0.6) 

Unguenti aquse rosse 5j (30.0). — M. 

S. — Apply locally. 

Several clinicians have recommended the treatment of smallpox by 
touching the vesicles in limited areas each day with a small brush or 
a stick dipped in the pure drug. It is claimed that in this way 
pustulation is decreased, secondary fever is diminished, and pitting 
is lessened. 

In enlarged glands which have not gone on to suppuration intra- 
glandular injections of phenol by means of a hypodermic needle 
are of value in a large number of cases, the solution used being no 
weaker or stronger than 2 per cent.; 5 to 10 minims (0.3-0.6) of 
this solution are sufficient for each gland. In the treatment of 
buboes 10 minims (0.6) of a solution of 8 grains (0.5) to the ounce 
(30.0) may be injected into the swelling, the skin being first benumbed 
by an ether spray. This is a most successful treatment. The same 
treatment may be applied in chronic synovitis and repeated every 
three days, and carbuncles may also be so treated with great success 
if this measure be used early enough to abort the trouble. Boils can 
be aborted by wrapping a bit of cotton around a toothpick, dipping 
it in the pure acid and then boring it into the center of the boil. 

Phenol is rarely used directly over wounds in dressings at present 
unless the dressing be one of phenolized oil. Other drugs, or rigid 
asepsis, have supplanted it when used in this way, but surgeons 
have returned to its employment as a useful antiseptic when used in 
pure form to swab out open wounds that are infected. The use of 
the phenolized spray over wounds has been found to do more harm 
than good, and it should never be employed. 



PHENOLSULPHONATES OF ZINC AND SODIUM 435 

A valuable application for burns, small wounds, and abrasions that 
are probably infected is one composed of phenol and camphor. 
Three parts of camphor and 1 part of phenol are mixed, the crystals 
of phenol being first liquefied by heat. The mixture after several 
hours becomes perfectly blended and part of its odor is dissipated if 
the bottle holding it is left open for a few days. This preparation 
will not harm the tissues nor cause pain as phenol does when not 
mixed with camphor, and may be applied with absorbent cotton 
or gauze or with petrolatum. Applied undiluted it is a useful 
application in tonsillitis in its early stages or it may be used 1 to 
500 as a gargle in septic pharyngitis. A 1 per cent, solution may be 
used in burns. 

As a disinfectant phenol ranks among the poorest : 1 to 2 per cent, 
solutions, however, kill most spores and germs. 

Untoward Effects.— Phenol when applied as a dressing, even in as 
weak a strength as 3 per cent., to a finger or toe may cause gangrene 
of the part severe enough to destroy it or to require amputation, but 
my dermatological colleague Dr. Stelwagon told me that he had 
never seen this untoward effect although he often employed the 
drug. Such strengths applied to the skin of the trunk rarely pro- 
duce evil effects, probably because the circulation is not so completely 
cut off by the action of the drug on the bloodvessels. (See Plate I.) 

Administration.— Phenol ointment (Unguentum Phenolis, U. S.; 
Unguentum Acidi Carbolici, B. P.) and the glycerite (Glyceritum 
Phenolis, U. S.) and liquefied phenol Phenol Liquefactum, U. S.) are 
the only official preparations of phenol in the U. S. P. In the B. P. 
the following preparations are official: Acidum Carbolicum Lique- 
factum, given in the dose of 1 to 2 minims (0.05-0.1); Glycerinum 
Acidi Carbolici, Trochiscus Acidi Carbolici, and Suppositorium Acidi 
Carbolici. 

PHENOLPHTHALEIN. 

Phenolphthaleinum, U. S. and B. P. originally used as a test for 
acids and alkalies, has come to be generally employed by many 
practitioners as a laxative to overcome habitual constipation. It may 
be given alone in pill or tablet. When given in the ordinary dose of 
1 "to 2 grains (0.06-0.12) at bedtime it produces a free, evacuation 
without griping and no effect on the general system even when 
given .over a long period of time. It is eliminated almost entirely 
in the feces, but if taken constantly a skin eruption called erythema 
perstans sometimes develops and then changes into an erythema 
circinata. 

PHENOLSULPHONATES OF ZINC AND SODIUM. 

The phenolsulphonates of zinc (Zinci Phenolsulphonas, U. S.) and 
sodium (Sodii Phenolsulphonas, U. S.) are largely employed by some 
practitioners as mild antiseptic local stimulants, either in powder 



436 DRUGS 

or in solution, on ulcers and sores. Much more commonly they are 
given internally for the production of gastro-intestinal antisepsis 
when there is diarrhea with fetid, ill-smelling stools, as in the bowel 
disorders of hot weather in children or adults, or in the course of 
typhoid fever. How much good they do in the latter disease, so far 
as the disease itself is concerned, is uncertain, but they undoubtedly 
render the stools less foul and tend to check the diarrhea. The 
phenolsulphonate of zinc is the better of the two for these purposes. 
The dose is 2 to 3 grains (0.12-0.2) in pill four or five times a day. 
The phenolsulphonates are probably eliminated from the body 
unchanged. Sometimes good results follow the use of cascara 
sagrada with these salts in cases of constipation with flatulence and 
signs of auto-intoxication. 

PHENYL SALICYLATE. 

(See Salol.) 

PHOSPHORIC ACID. 

The pure acid is rarely employed in medicine, but when given is 
used in 2- to 8-minim (0.1-0.5) doses. In the form of dilute phos- 
phoric acid (Acidum Phosphoricum Dilutum, U. S. and B. P.) it is 
widely employed in the dose of 20 minims to 1 dram (1.3-4.0), 5 to 
20 minims (0.3-1.2), B. P., as a tonic and gastric stimulant. It is 
not a food to the nervous system, does not resemble phosphorus 
in its physiological action, and is not to be employed in its place. 
It does good in nervous exhaustion simply by stimulating the stomach 
and thereby aiding that organ in the digestion of food. Phosphoric 
acid is also official in the B. P. as Acidum Phosphoricum Concentratum. 

PHOSPHORUS. 

Phosphorus, U. S. and B. P., is a non-metallic element, generally 
obtained from bones, and is very soluble in oils, less so in ether and 
alcohol. Its odor is characteristic and peculiar. When placed in 
a dark room after exposure to light it is luminous, and if exposed 
to the air will ignite. It should be kept under water in tightly- 
stoppered bottles. Very commonly it is contaminated by arsenic 
and sulphur. 

Physiological Action.— Phosphorus is found in large amount, com- 
paratively speaking, in the bones and in the nervous system, and is a 
stimulant to the growth of both. It acts, therefore, as a direct 
tonic to nervous tissue and is a producer of bone. Upon tissue- 
waste the drug acts as a depressant, thereby preserving the body, 
as it decreases the elimination of urea and diminishes the quantity 
of carbonic oxide exhaled. 

Upon the growth of bones phosphorus has a most remarkable 
influence, causing, when it is given to young animals, great increase 
in the size of these parts. The first change noted is an enlargement, 



PHOSPHORUS 437 

which consists in a jelly-like mass containing little or no bone salts, 
and this is finally converted into a very hard material which may 
fill the entire canal in the center of the bone. Kissel has stated that 
this does not occur, but his results must be doubted in view of the 
thorough studies of Wegner. 

Acute and Chronic Poisoning.— When phosphorus is taken in poison- 
ous dose, often from the ends of certain matches, no symptoms may 
come on for eight or ten hours. At the end of that time the peculiar 
taste of phosphorus may be noted in the mouth, the breath is heavily 
laden with its odor, and burning pain in the esophagus, stomach, and 
abdomen becomes a pressing symptom. Vomiting and purging now 
assert themselves, and both the matters which are vomited and those 
which are passed from the bowels may be luminous in the dark, 
owing to the presence of phosphorus. The vomit at first consists 
of food, then mucus, then bile, and then perhaps blood. All the 
symptoms of a mild gastro-enteritis may develop, but it is to be 
noted that constipation of an obstinate type may be present instead 
of purging. Very soon the liver increases in size, and gives rise to 
general hypochondriac pain and tenderness as well as local swelling. 
At the end of twenty-four hours, or perhaps after the second day, a 
cessation in the symptoms occurs, and, if the physician be not on 
his guard, this will lead him to a hopeful prognosis, but in the course 
of a few hours jaundice begins in the conjunctiva and then extends 
over the entire body. With the onset of jaundice the vomiting and 
pain return with renewed vigor. The matters vomited have often 
the color of "coffee grounds," due to exuded and altered blood. 
The bowels are absolutely confined, or the few hard masses of fecal 
matter which are passed are white and clay-like because of the 
absence of biliary coloring matter. There is no bile in the vomit 
in this stage, because the hepatic ducts have been closed by the 
inflammation which has been produced in the liver. Later, nervous 
symptoms ensue. Muscular twitchings, headache, vertigo, wild 
delirium, erotic convulsions, and, finally, unconsciousness and death 
occur. Sometimes the convulsions occur just before dissolution. 
Even if the patient survives the acute stage of the poisoning, he 
generally dies of the changes produced in his vital organs, which 
consist in widespread fatty degeneration. These fatty changes occur 
even in the acute form of the poisoning. Atrophy of the liver, 
destruction of the gastric tubules, pancreatic involvement, and kidney 
degenerations aid in producing the ultimately fatal results. 

During poisoning by phosphorus the urine is scanty and perhaps 
albuminous, and is peculiar because of the unusual substances which 
are found in it. The most unusual of these is sarcolactic acid, which 
results from breaking down of the muscular tissues. Leucin and 
tyrosin are also found, and tube casts with fatty globules in them 
are seen. Free fat-globules may also occur. Bile acids and bile 
coloring matter are found in large amount, and the urine is generally 



438 



DRUGS 



dark colored for this reason. As phosphorus is eliminated in the 
urine as hypophosphoric acid, this substance is also present. 

The symptoms of phosphorus poisoning may so closely resemble 
those of acute yellow atrophy of the liver as to make a differential 
diagnosis impossible unless some evidence of the presence of phos- 
phorus is obtainable. 

In chronic poisoning by phosphorus, usually caused by the inha- 
lation of its fumes, by far the most common lesion is necrosis of the 







Fig. 61. — Showing the fat-granules produced in the liver in phosphorus poisoning. 

(Kast and Rumpler.) 

lower jaw, which may be widespread or limited. The phosphorus 
by attacking the periosteum exposes it to infection, and pyogenic 
organisms attack the bone. Sometimes the tubercle bacillus causes 
the necrosis. Phosphorus necrosis never occurs in those who have 
no solution of continuity in the teeth or gums. It has been said 
that pans containing turpentine when set around the work-room will 
protect the workmen, but this is certainly incorrect. Since laws have 
been passed forbidding the use of yellow phosphorus in the making 
of matches this condition is very rarely seen. Some cases develop 



PHYSOSTIGMA 439 

in the making of phosphor-bronze. The red amorphous phosphorus 
and the sesquisulphide used in safety matches is non-poisonous. 

Treatment of Acute Poisoning.— The antidote to phosphorus 
is generally taught to be the sulphate of copper, which will also act 
as an emetic if given in excess, but studies made by Thornton in 
my laboratory at the Jefferson Medical College prove that when 
given in a dose large enough to be efficient it is as dangerous a poison 
as the phosphorus. Peroxide of hydrogen or permanganate of 
potassium are probably the best antidotes, as they convert the 
phosphorus into phosphoric acid. Oil of turpentine, in America, is 
not only valueless as an antidote, but harmful, for only old, ozonized 
French oil of turpentine is antidotal in its influence. As phosphorus 
is soluble in oils, we simply aid in its absorption if any such substance 
are given. 

Therapeutics.— Owing to its influence on the development of bone, 
phosphorus may be used in rachitis and osteomalacia. It is also 
useful in the sweats of general or nervous debility and in nervous 
exhaustion, and in some cases of melancholia depending upon over- 
work. In the course of prolonged exhausting diseases, as typhoid 
fever or typhoid pneumonia, the drug is of service if the nervous 
system seems to be particularly affected, and in convalescence it 
is of service in aiding to build up the shattered forces of a patient. 

In the sequelae of acute and chronic alcoholism and in morphiomania 
it is of service. Phosphorus is also employed in sexual exhaustion 
or abuse. In boils and carbuncles and similar disorders phosphorus 
is useful, particularly so in acne indurata. In pneumonia some physi- 
cians use minute doses with the belief that it aids in the production 
of resolution. Probably it does good in these cases by stimulating 
or supporting the nervous system. 

In the neuralgia from nerve-depression and in cerebral softening and 
meningitis of a chronic type phosphorus may be given with advantage. 
Although all these statements are based upon the opinion of other 
writers the author has to confess that his use of this drug has been 
disappointing. 

The dose of phosphorus is y^- to -^ grain (0.0006-0.0012) in pill 
form {Pilules Phosphori, U. S. and B. P.), but it may be gradually 
pushed to 2V grain (0.003) if urgently needed. Phosphorated oil 
(Oleum Phosphor -atum, B. P.) and Spiritus Phosphori are given in 
the dose of 1 to 5 minims (0.05-0.3). Elixir Phosphori is given in 
the dose of 15 minims to 1 dram (1.0-4.0). 

The beginning dose of phosphorus should not be above x ^ grain 
(0.0006), for fear of some idiosyncrasy. 

PHYSOSTIGMA. 

Physostigma, U. S. (Physostigmatis Semina, B. P.), is a seed derived 
from Physostigma venenosum, a tree of West Africa, often called 



440 DRUGS 

Calabar bean, yielding, when assayed by the U. S. P. process, not 
less than 0.15 per cent, of alkaloids. It contains two alkaloids, 
eserine or physostigmine and calabarine. The former is the more 
important from a medical point of view. 

Physiological Action.— When a very large dose of physostigma is 
given by the mouth it often produces some pain in the stomach and 
a sense of oppression and weakness. The pulse becomes slow, the 
respiration is depressed, and the pupils are contracted. Calabar 
bean in poisonous dose is a general paralyzant, but if the alkaloid 
calabarine be present in excess, it may be convulsant. 

Nervous System.— On the spinal cord in poisonous dose this drug 
acts as a depressant poison, particularly affecting the sensory tracts. 
On the motor nerves it exerts no influence unless given in toxic doses, 
when it depresses their peripheral ends. The sensory nerves escape, 
but sometimes even they are involved. On the voluntary muscles 
the drug in these doses causes twitchings. In medicinal doses the 
drug is a stimulant to unstriped muscular fiber and acts as a mild 
nervous sedative. 

Circulation.— Calabar bean causes little circulatory change, but 
poisonous doses at first produce a rise of arterial pressure, due to a 
direct stimulation of the heart and of the muscular coats of the 
vessels. It slows the pulse by peripheral stimulation of the vagi. In 
medicinal dose its circulatory effect is not marked, but is depressant 
rather than stimulant. 

Respiration.— In moderate amount calabar bean does not affect 
respiration, but in poisonous dose it produces death by paralysis of 
the respiratory center. 

Pupil.— Physostigma causes myosis or contraction of the pupil 
by stimulation of the circular muscular fibers of the iris, and not by 
depression of the sympathetic fibers nor by stimulation of the 
oculomotor fibers, nor again by causing contraction of the blood- 
vessels of the iris. It decreases intra-ocular tension, produces tempo- 
rarily an increase in the power of accommodation for near objects, 
and then causes spasm of accommodation. The myosis usually 
develops in about eight to fourteen minutes after the drug is dropped 
in the eye, and reaches the maximum in thirty minutes, lasting for 
from six to eight hours. The partial influence may last, however, 
for four or five days. 

Alimentary Tract.— Physostigma is a stimulant to intestinal 
peristalsis, increasing the muscular activity in the walls of the gut 
and acting as a tonic to these fibers. 

Poisoning.— Poisonous doses of physostigma cause muscular trem- 
ors, followed by complete muscular relaxation. The pupils contract, 
the respirations become slow and irregular, and all reflex action 
fails. Vomiting or purging may or may not occur. 

Treatment of Poisoning.— This consists in the use of atropine, 
which is the physiological antidote; in the application of heat to 



PICRIC ACID 441 

the body, and the use of respiratory and cardiac stimulants, such 
as digitalis, alcohol, or ammonia. 

Therapeutics.— Calabar bean has been employed in many affections, 
such as trismus neonatorum, tetanus, and other spasms, with only 
moderately good results. It is, however, of value in atony of the 
bladder and intestine and in catarrh of the bowels. Combined with 
mix vomica the author has used eserine with advantage in cases of 
gastric and intestinal dilatation. Some physicians think it of value 
in cases of tympanites, but in a limited use of it in certain severe 
cases of pneumonia with tympanites the writer has not found it 
of value. 

It has also been used advantageously by surgeons to overcome 
post-operative tympanites in the dose of -£§ grain (0.002) by hypodermic 
injection with or without strychnine. I have never seen it do good. 

In bronchial asthma and emphysema it aids in expulsion of the mucus 
by its influence over the muscular fibers in the walls of the air-tubes. 
It is also useful in purgative pills to stimulate the muscular fibers of 
the intestine. (See Constipation.) 

In the eye, in the strength of 1 to 2 grains to the ounce (0.06- 
0.12:30.0) of water, eserine is used in the treatment of corneal ulcera- 
tions, for the relief of glaucoma, and to diminish high intra-ocular 
tension. If, for any reason, atropine mydriasis is to be rapidly 
overcome, eserine may be used, but it is not so powerful a myotic 
as atropine is a mydriatic, and it requires larger amounts of the 
solution to produce contraction than it took of atropine to cause 
mydriasis. 

Administration.— Physostigma is used in the form of the extract 
{Extr actum Physostigmatis, U. S. and B. P.) in the dose of J grain 
(0.008), which may be readily increased to J grain (0.015), \ to 1 
grain (0.015-0.06), B. P. This extract should contain 2 per cent, 
of ether-soluble alkaloids. 

The tincture ( Tinctura Physostigmatis, U. S.) should contain 0.014 
gram of ether-soluble alkaloids in 100 cc and is given in the dose of 
5 to 30 minims (0.3-2.0). 

Eserine is usually employed in the form of Physostigmvrux Salicylas, 
U. S., and may be used in the dose of ^o grain (0.0008) three times 
a day. The sulphate is much more soluble, and is generally to be 
employed. The salicylate is largely used, nevertheless, by ophthal- 
mologists. Lamellw Physostigmina, B. P., each contain 10 1 00 grain 
(0.00006) of physostigmine sulphate. The dose of both salts of 
eserine is ^ to -^ grain (0.0006-0.0008). 



PICRIC ACID. 

Picric acid, Trinitrophenol, U. S. (Acidum Picricum, B. P.), occurs 
in light yellow scales or needles without odor, and is chiefly used in 



442 DRUGS 

the arts as a dye. Its uses in medicine are limited. It has been 
found exceedingly efficacious in solution in the treatment of severe 
burns and scalds. This solution is made as follows: 

1$ — Acidi picrici gr. lxxv-3ij (5.0-8.0) 

Alcoholis fSiiss (75.0) 

Aquae destillatse Oij (960 cc). — M. 

After the burn is cleansed of dirt and charred clothing, strips of 
sterilized gauze are soaked in this solution and applied to the part. 
Over this is placed a pad of dry absorbent cotton which is fastened 
by a light bandage. The dressing rapidly dries, and may be left 
in place for several days. It is then moistened with the solution so 
as to soften it, is removed, and then a fresh dressing is applied for a 
week. All blisters should be pricked. At first the acid causes 
some pain, but in a short time this dressing relieves pain. It prevents 
suppuration, hastens healing, and results in a smooth cicatrix. As 
this dressing stains the hands, the physician should use rubber 
gloves when applying it. The existence of marked renal irritation 
should make us cautious in applying this acid solution to large sur- 
faces, lest absorption occur. 

Picric acid in 5 per cent, solution may be advantageously used as 
a substitute for tincture of iodine to disinfect the skin prior to opera- 
tion. It possesses the advantage that the skin does not have to be 
dry when it is applied as is the case with iodine. 

To remove the stain of picric acid from the skin, wash the hands 
in a solution of lithium carbonate in water in the strength of 1 dram 
(4.0) to 1 quart (1000 cc). 

PILOCARPUS. 

Pilocarpus, U. S., is the leaflets of a South American tree, Pilo- 
carpus microphyllus, or Pilocarpus jaborandi, yielding, when assayed 
by the U. S. P. process, not less than 0.5 per cent, of alkaloids. It 
contains two alkaloids, known as pilocarpine, and isopilocarpine. 
Jaborine is a combination of these alkaloids and a resinous sub- 
stance. The alkaloid pilocarpine is non-crystallizable and occurs as 
a soft mass, but the salts of pilocarpine are crystallizable. 

Physiological Action.— When pilocarpus is taken in medicinal dose 
by a healthy man it causes a deep flushing of the face and neck, 
followed by the outbreak of a profuse sweat, which, though beginning 
in these regions, rapidly spreads over the entire body. Accompany- 
ing the sweat, salivation is often exceedingly profuse, so that saliva 
dribbles from the mouth. The sweat lasts from two to five hours. 
Nausea frequently comes on, and severe vomiting may appear in 
susceptible persons either during or after the sweating. Some indi- 
viduals are singularly insusceptible to the diaphoretic influence of 
pilocarpus and this is particularly so, according to Ringer, with 



PILOCARPUS 



443 



children, who will often take as much as 60 grains (4.0) of the crude 
drug before they perspire. 1 

Nervous System. —Moderate doses given to men have no effect 
on this part of the body. 

Circulation.— In large doses there is no doubt that jaborandi 
acts as a cardiac depressant rather than a stimulant. The drug 
causes in the lower animals a slow pulse and decreased arterial 
pressure, in moderate quantities, the first change being due to an 



\iVWVj\^v 



TI 



III 



IV 




Fig. 62. — Parts of a tracing showing the effect of pilocarpine in depressing blood- 
pressure, and the stimulant effect of atropine upon blood-pressure in the circulation 
of a dog. (After Schmiedeberg.) I shows the pulse-rate and blood-pressure unaffected 
by drugs. II, pilocarpine injected, which slows the pulse from 28 in ten seconds to 
19 in ten seconds, and lowers the blood-pressure from 126 to 96. Ill, further depres- 
sion and slowing; pressure, 70. IV, atropine given, which raises blood-pressure to 
145 and pulse-rate to 30. 



action on the inhibitory centers in the heart or on the peripheral 
vagi. (See Fig. 62.) In man the drug does not slow the pulse, 
but quickens it very markedly, often as much as 40 to 50 beats per 
minute. Although the pulse in animals is generally made stronger 
by its use, in man it is generally made weaker. 

1 The writer has reported a case (see Idiosyncrasy) in which a woman of thirty 
years received f grain of the muriate of pilocarpine hypodermically in half an hour 
without any effect. 



444 DRUGS 

Stomach.— Jab orandi sometimes produces nausea and vomiting 
by irritating the stomach and perhaps the vomiting center. 

Temperature.— Jaborandi lowers bodily temperature to a con- 
siderable degree, probably by the dilatation of the peripheral capil- 
laries and the profuse sweat which it produces. This fall is sometimes 
preceded by a brief rise. 

Kidneys and Tissue-waste.— Upon the kidneys jaborandi acts 
very slightly or very strongly, according to the dose that is given. 
Large doses, which produce a profuse sweat, naturally decreases the 
urinary secretion, but small ones undoubtedly increase it. Upon the 
tissue-changes in the body under pilocarpine no researches have been 
made, but it is an undoubted fact that in disease the excretion of 
urea is largely increased under the influence of this drug. 

Eye.— Jaborandi contracts the pupil by stimulating the peripheral 
ends of the oculomotor nerve in the iris. 

Skin and Secretion.— The amount of sweat caused by the drug 
in man may equal as much as a pint, and it is generally first acid, 
from the secretions of the sebaceous glands, then neutral, and finally 
alkaline. The sweating is not primarily due to vasomotor palsy, 
but to stimulation of the ends of the nerve supplying the glands and 
of the sweat-glands themselves. The sweat usually lasts about two 
or five hours. Sometimes excessive salivary secretion supplants that 
of the skin. 

Pilocarpine increases the gastric, salivary, and lacrimal secretions, 
as well as that of the skin and kidneys. It also seems to have con- 
siderable influence over the secretion of milk. 

Therapeutics.— Jaborandi, or, better still, its alkaloid, pilocarpine, 
is of some value for the relief of dropsy of the renal type. (See 
below.) In cardiac dropsy it is generally too depressing, and the 
author knows of more than one case in which a fatal result 
speedily followed its use under these circumstances. For pleural 
transudates it has been used, but more efficient remedies are elate- 
rium, or salines given in concentrated form and at the proper 
time of the day. (See Magnesium Sulphate and Dropsy.) Better 
than all these is thoracentesis. Spaulding and de Schweinitz have 
both recommended very highly the hypodermic use of pilocarpine 
in the dose of ^V to ^ grain (0.005-0.006) a day for opacities of the 
vitreous humor of the eye. The fluidextract of jaborandi may be 
employed, but is apt to nauseate the patient. Diaphoresis should 
not be produced. Because of its myotic influence on the pupil pilo- 
carpine is of very great value in the treatment of all conditions of 
the eye associated with increased intra-ocular pressure. It is so good 
a myotic as to be rapidly supplanting eserine for this purpose with 
some clinicians. The strength of pilocarpine solution for this pur- 
pose is 1 to 4 grains (0.06-0.25) to the ounce (30.0). It should be 
dropped into the eye, 1 or 2 drops at a time, every hour until the 
patient is relieved. Pilocarpine is also useful as an ocular tonic to 



PILOCARPUS 445 

relieve eye-pain after excessive use of the eyes, in the strength of 
yo grain (0.006) to the ounce (30.0). A few drops of this solution 
may be dropped into the eye three times a day. This solution 
should have a little boric acid (4 grains) added to it to prevent 
fungus growth (See Asthenopia.) A useful formula is as follows: 

1$ — Pilocarpini nitratis gr. 2V (0.003) 

Holocainse hydro chloridi gr. j (0.06) 

Aquse destillatse f Sj (30.0) 

S. — Use as an eye tonic dropped in eyes t. i. d. 

Clinical reports show that pilocarpine in small doses is a good 
remedy in tobacco and alcoholic amblyopia. 

Mitkowski has tried pilocarpine in catarrhal jaundice of a persist- 
ent type with great benefit, in the hypodermic dose of J grain (0.01) 
every other day for three weeks. In uremic poisoning pilocarpine is 
theoretically the most efficient and rapidly acting remedy that we 
have, and when used in Bright' s disease it may be of value; but the 
frequency with which its use has been followed by pulmonary edema 
or a transudation of fluid into the bronchi has very properly made 
many practitioners afraid to employ it. 

Care should always be exercised in the use of the drug lest cardiac 
depression ensue, and alcohol or strychnine may often be used with 
advantage to guard against this accident. The general consensus 
of opinion is that in the nephritis of middle or advanced life with 
cardiac changes it is contraindicated. The author never uses it in 
chronic parenchymatous nephritis. In the convulsions of pregnancy 
pilocarpine, while theoretically useful, has been proved by experi- 
ence to do more harm than good through its depressing influences, 
although the drug in small doses often increases renal activity. 
The hypodermic dose of pilocarpine as a renal stimulant should be 
about g^-Q to yV grain (0.002-0.003). In some forms of profuse sweat- 
ing, such as come on at night in cases of general debility, pilocarpine, 
if given hypodermically or by the mouth about two hours before 
the sweat in the dose of ^V grain (0.003), is often useful even where 
atropine fails. The good effect is produced by stimulating the 
sweat-glands and so overcoming their atony. 

J. M. Da Costa and Barr highly recommended the hypodermic 
injection of pilocarpine in erysipelas as a preventive and cura- 
tive measure in the early stages of this disease, and their reports are 
so encouraging as to warrant a careful trial of the method. The 
proper dose is J grain (0.01) every three hours until free sweating 
ensues. After this is accomplished the doses may be repeated every 
four or six hours. The author would fear that such active treatment 
might seriously affect the strength of the patient unless stimulants 
were also used. 

In cases of obstinate aural vertigo a most efficient treatment is the 
hypodermic use of pilocarpine every few days in sufficient dose to 



446 DRUGS 

produce some salivation. The patient must lie down or go to bed 
after the dose is given. 

Pilocarpine certainly has a decided effect in encouraging the 
growth of hair, and applied locally will often do good in partial 
baldness. If too much pilocarpine is used, it is apt to cause the 
development of small pustules about the hair-follicles. Bartholow 
recommended the following application for baldness : 

1$ — Fluidextracti pilocarpi f5j (30.0) 

Tincturse cantharidis f Bss (16.0) 

Linimenti saponis f5iss (45.0). — M. 

The author has found the following prescription very efficacious 
in falling of the hair. 

1$ — Fluidextracti pilocarpi f5j (4.0) 

Tincturse capsici f5j (30.0) 

Tr. cantharidis f 3ss (2.0) 

Olei ricini f 3J (4.0) 

Alcoholis q. s. fgiv (120.0).— M. 

S. — Apply with friction in spots to the scalp, night and morning. 

Antagonisms of Jaborandi.— Jaborandi is a physiological antidote 
to atropine and to agaricin. Four times the dose of pilocarpine must 
be used to counterbalance a dose of atropine. Vomiting produced 
by pilocarpus is to be antagonized by morphine. 

Untoward Effects.— Dimness of vision, vomiting, sudden collapse 
swelling of the salivary glands and tonsils, hiccough and strangury 
,are sometimes met with after using pilocarpus. Sometimes bloody 
leucorrhea is seen. The vomiting can usually be prevented by full 
doses of chlorodyne. Occasionally pulmonary edema develops. 

Prentiss has called attention to the fact that the continued use of 
pilocarpine may cause the hair to become coarse and dark. 

Administration.— The dose of jaborandi is 40 grains (2.6) used in 
the form of the powdered leaves in infusion. The fluidextract 
(Fluidextractum Pilocarpi, U. S.; Extractum Jabprandi Liqiddwm,, B. 
P.) contains 0.4 gram of the alkaloids of pilocarpus in each 100 
cc, and should be used in the dose of 10 to 40 minims (0.6-2.6), 
5 to 15 minims (0.3-1.0), B. P. Pilocarpine is far superior to jabo- 
randi, in that it does not so often produce nausea and vomiting. 
It is used in the form of the hydrochloride (Pilocarpine Hydro- 
chloridum, U. S.), in the dose of from J to \ grain (0.008-0.03) hypo- 
dermically, or J to J grain (0.15-0.03) by the mouth and in the form 
of the nitrate (Pilocarpine Nitras, U. S.) in the same dose as the 
hydrochloride. 

The additional preparations of the B. P. are— the tincture (Tinc- 
tura Jaborandi), dose \ to \ fluidounce (8.0-16.0); and the nitrate 
of pilocarpine (Pilocarpine Nitras), | to \ grain (0.008-0.03). 



PIPERAZINE 447 



PIMENTA. 

Pimenta or Allspice is the nearly ripe fruit of Pimento, officinalis, 
a tree of the West Indies. It contains an official volatile oil {Oleum 
Pimento?, U. S. and B. P.), used for flavoring purposes, as a constit- 
uent of spice plasters, in diarrhea mixtures, or as a carminative. 
It will also prevent the griping of purgative medicines. The dose of 
the oil is 1 to 5 minims (0.06-0.3). Aqua Pimentos (B. P.) is given 
in the dose of 1 to 2 ounces (30.0-60.0). 



PIPERAZINE. 

Piperazina is a substance, the chemical formula of which is C 4 Hi N 2 , 
introduced into medicine for the treating of the so-called uric-acid 
diathesis. It is not stable, and when exposed to the air attracts 
water and carbonic acid; so it must be kept in tightly-stoppered 
bottles. Aqueous solutions are decidedly alkaline, but do not have 
any distinct taste. 

Piperazine is peculiar in its power to dissolve uric acid, dissolving 
twelve times as much as will carbonate of lithium, and it is also 
entirely soluble in water, which lithium is not. When taken into the 
body the drug is partly oxidized and partly eliminated unchanged. 
Theoretically piperazine, when taken into the body, forms with uric 
acid a urate of piperazine, which is soluble and readily eliminated. 
Experiments to determine this point have been made with very 
satisfactory results, and repeated clinical observation has shown that 
the administration of the drug causes an increase in the amount of 
urea in the urine with a decrease in the uric acid, indicating that 
under its influence oxidation is more complete. 

Therapeutics.— Piperazine is used for the purpose of preventing 
the formation of renal and vesical calculi in the so-called uric-acid 
diathesis, and also in cases where the excess of uric acid in the urine 
tends to produce irritation of the bladder. Similarly, its action has 
been found of value in treating vesical irritation due to this cause by 
washing out the bladder with a solution of piperazine of the strength 
of 1 per cent. Piperazine has also been injected into uric-acid 
deposits about the body or applied to the broken-down surfaces of 
these deposits in 1 per cent, solution, but the author has not been 
favorably impressed with this method, and would advise against 
its use— first, because it does little if any good, and, second, because 
the method is painful and apt to cause sloughs by interfering with 
nutrition of the skin, which is already lacking in health. 

The dose of piperazine is 15 grains (1.0) in twenty-four hours. 
It is best given by dissolving this amount of the drug in 1 pint (480 
cc) of water, and directing the patient to take a wineglassful of 



448 DRUGS 

the solution frequently through the day. Owing to the effect upon 
a drug of exposure to air, it cannot be given in pill or powder, and 
should be freshly mixed each day. The writer has failed to obtain 
any results from the use of this drug in his practice. 

Stewart has noted, as untoward effect of full doses of piperazine 
tremors, hallucinations, and clonic spasms. 

Lycetol is a substance closely allied to piperazine, and is used in 
medicine for the same purposes. Dissolved in water it has a taste 
somewhat like lemonade. Unlike piperazine, it is not hygroscopic 
and will keep indefinitely. The dose of lycetol is 15 to 30 grains 
(1.0-2.0) a day, well diluted with water, to which a little sugar may 
be added to improve the taste. Usually it is best to give the drug 
in carbonated water, and to begin with small doses, which are to 
be gradually increased in size. 

PITCH. 

Pix is a resinous exudation derived from several species of pines, 
firs, and spruces, and is, in one of its forms, obtained by the evapo- 
ration of wood-tar. It is used for various purposes, according to 
its derivation. Burgundy Pitch (Pix Burgundica, B. P.) is derived 
from Norway spruce, or Abies (Picea, B. P.) excelsa, a plant of 
Europe and Asia. It softens and melts at the temperature of the 
body and is useful for plasters. In muscular rheumatism and in 
chronic bronchitis pitch is a mild and fairly useful local remedy for 
external use. In the form of the plaster (Emplastrum Picis, B. P.), 
and in the form of warming plaster (Emplastrum Picis Cantharida- 
tum), it is employed for the relief of deep-seated sprains and bruises, 
and acts as a mild counterirritant, which may blister a tender skin. 
Canada pitch (Pix canadensis) is obtained from the hemlock spruce 
of Canada and the United States, and is used for the same purposes 
as Burgundy pitch. The Canada-pitch plaster (Emplastrum Picis 
Canadensis) is employed for the same conditions as the plaster of 
Burgundy pitch. 

PITUITARY GLAND. 

The posterior lobe (infundibulum) of the pituitary gland is now 
largely used in medicine. In dried form it is official in the U. S. P. 
as Hypophysis Sicca, and a liquid extract is also official as Liquor 
Hyphophysis, U. S. The preparation in liquid form most generally 
used for all purposes is called "pituitrin." 

The physiological action of this substance when given intraven- 
ously is almost identical with adrenalin in that it is a stimulant to 
the muscular coats of the bloodvessels, but its action, although 
more prolonged than that of adrenalin, is less powerful and 
less sudden in onset. It slows the pulse-rate. Locally applied to 



PITUITARY GLAND 



449 




o 

. to 



29 



450 DRUGS 

mucous membranes it induces a similar ischemia to that caused by 
adrenalin. Upon the parturient uterus after the os . is dilated it 
acts as a powerful stimulant. It also stimulates intestinal peristalsis 
and the muscular coats of the bladder. It increases urinary flow, 
not by stimulating the epithelium of the kidney, but by increasing 
the blood-pressure in the renal vessels. It also in some cases increases 
the secretion of milk. 

Therapeutics.— Pituitrin for the reasons just given finds its chief 
use as an oxytoxic which is not to be given until the os is dilated to 
the size of a quarter of a dollar and until the physician is sure that 
the birth canal is not obstructed. Its action is so prompt that after 
it is given the physician should not leave the patient. If after its 
use labor threatens to be too precipitate, chloroform should be given. 
It has largely displaced the forceps in slow labor due to feebleness 
and uterine inertia. It should never be used to hurry delivery in 
perfectly normal labor. This drug is also used as a circulatory 
stimulant in collapse, to control surgical shock, for the relief of post- 
operative intestinal torpor and to remove tympanites in the course of 
the acute infectious diseases. It is also used in atony of the bladder. 
When used as an oxytoxic the dose is usually 5 to 10 minims (0.3- 
0.65), but twice or thrice these amounts are used to stimulate peri- 
stalsis. Where used locally to constrict engorged mucous mem- 
branes, as in hay fever and acute rhinitis, it is best to dilute it from 
three to ten times with normal salt solution. Given too freely it may 
induce glycosuria. On the other hand, cases occur in which through 
inactivity of the posterior lobe a high degree of sugar tolerance is 
established (250-400 grams a day). Such cases present obesity in 
which the fat is deposited above the clavicles, at the front and sides 
of the abdomen, on the neck or the arms and about the upper part 
of the thighs. The temperature is subnormal and the pulse slow. 
The value of pituitrin in these cases is still to be determined. It 
should be used hypodermically. 

Although, as already stated, the posterior part of the pituitary 
usually increases urinary flow, nevertheless the administration of 
pituitrin hypodermically is the best remedy for diabetes insipidus 
so far discovered. 

• The exact physiological and therapeutic value of the anterior lobe 
of the pituitary body is still undetermined. It would seem to be 
indicated in cases of delayed development in childhood, physical, men- 
tal, and sexual, associated with adiposity. Some physicians have 
prescribed the anterior lobe for sexual atony in adults. It is given 
in the form of the desiccated powder in the dose of 2 to 3 grains 
(0.1-0.25) three times a day. Under the name of Antuitrin a clear, 
sterile, aqueous solution, of the soluble extract of the anterior lobe, is 
now on the market, put up in sterile ampoules for hypodermic use. 
The dose of antuitrin 8 to 16 minims (0.5-1.0) given once a day by 
the needle. 



POMEGRANATE 451 

PODOPHYLLUM. 

Podophyllum, U. S., May apple or mandrake, is the rhizome and 
small roots of Podophyllum peltatum, a plant of the United States and 
Canada. Podophyllum contains a resin, podophyllin. 

Therapeutics.— Podophyllum is the slowest-acting purge official in 
the Pharmacopoeia. In small doses it is laxative, but is purgative 
and almost drastic in larger amounts. In overdose it may produce 
gastro-enteritis. The drug particularly excites the flow of bile, and 
is used as a cholagogue. It is best given when the stools are dark 
in color, calomel being indicated when they are light. The author 
has found the following prescription useful in cases of intestinal 
flatulence and indigestion with constipation: 

3— Podophyllin gr. v. (0.3) 

Euonymin gr. v (0.3) 

Leptandrin gr. v (0.3) 

Creosoti gr. x (0.6). — M. 

Fiant pilulse No. xx. 

S. — One pill once, twice or thrice a day. 

In children one or two months old who have hard, stony stools 
podophyllin is a good remedy. The dose should be given by dis- 
solving a grain of the resin in a dram of alcohol and using 2 drops 
or more of this on sugar once or twice a day. In children who suffer 
from summer diarrhea, in which the passages, consisting almost 
entirely of water, have a peculiar musty smell or a mouse odor, 
podophyllin in the dose of -fa to -fa grain (0.001-0.0012), repeated 
every few hours, is of service, seeming to control the passages and 
make them normal. This treatment will often succeed when all 
else fails. This statement is also true in regard to the chronic diar- 
rheas of adults, though the drug should be given in somewhat larger 
amounts in such cases. Podophyllin will also check vomiting in these 
doses in some instances, provided that the stomach is depressed 
and the liver is torpid. It should not be employed if the vomiting is 
due to irritation or inflammation of the stomach. 

Administration.— Podophyllum is used in the form of the extract 
(Extractum Podophylli), dose 1 to 5 grains (0.06-0.3); the fluid- 
extract {Pluidextr actum Podophylli, U. S.), dose 2 to 20 minims (0.12- 
1.3); and more commonly than all, as the Resina Podophylli, U. S., 
Podophylli Resina, B. P., or podophyllin, which is the best prepara- 
tion. The dose of this preparation is from -fa to fa grain (0.003- 
0.006) as a feeble laxative, and from fa to \ grain (0.006-0.03) as 
a purge, i to 1 grain (0.015-0.06), B. P. The tincture (Tinctura 
Podophylli, B. P.) is given in the dose of 5 to 15 minims (0.3-1.0). 

POMEGRANATE. 

Granatum, U. S., is the bark of the stem and root of Punica grana- 
tum. It is seldom used in America in its crude form. It contains 



452 • DRUGS 

an alkaloid known as pelletierine, this alkaloid being a colorless liquid 
soluble in 20 parts of water and readily miscible with ether, chloro- 
form, and alcohol. When to it acids are added it forms crystalline 
salts, of which four are used— namely, the tannate, the sulphate, the 
hydrobromide, and the hydrochloride. The first is most commonly 
employed, and is a yellowish powder possessing an astringent taste. 
It is soluble in 235 parts of water and 12.6 of alcohol. Its physio- 
logical action needs further investigation, but the drug in poisonous 
amounts paralyzes the peripheral ends of the motor nerves in a 
manner closely resembling the action of curare. Sensibility is pre- 
served. The loss of power is chiefly manifested in the lower limbs, 
in which at first there may be cramps. There may also be nausea 
and vomiting. 

Therapeutics.— Originally, pomegranate was largely used in the 
form of the rind of the fruit in decoction as a vegetable astringent, 
but this practice has ceased because of its disagreeable taste and 
effect upon the stomach. The ailments which were supposed to 
indicate its employment were serous diarrhea and profuse sweats. 
In some tropical countries the bark of the root is used as a vermifuge, 
and it is very efficient in removing the tapeworm. It is said that 
the bark of the root of the wild shrub is much more efficacious than 
that of the cultivated and more handsome plant. To be effective 
the dose of the decoction of the bark must be large. The drug is 
prepared by soaking 2 ounces (60.0) of the bark in 2 pints (960) of 
water for twenty-four hours and then boiling down to a pint (480). 
A wineglassful (30.0) of this is the dose which is generally given, and 
it may be repeated every hour until the whole amount is taken. 
The objection to this line of treatment is that it is unnecessarily 
severe, often purging and vomiting the patient excessively. The 
nausea produced is often great. Should purging fail to occur, it is 
necessary to give castor oil or other purge to dislodge the worm, and 
it is always necessary to starve the patient for twelve hours before 
the remedy is tried. 

The dose of pelletierine is 3 to 5 grains (0.2-0.3), and the tannate 
(PelletierincB T annas, U. S. and B. P.) is the salt usually employed. 
Practically, the only pelletierine used is the French preparation of 
Tanret. This preparation is put up in small vials; each contains a 
dose of 5 grains of the drug in solution ready to take. 

As large doses as 20 grains (1.3) of pelletierine have been used, 
but as serious paralytic symptoms have ensued after the ingestion of 
5 grains by a susceptible woman, not more than this amount should 
be given. When pelletierine is used, it should always be followed in 
two hours by a purge. Those who have used it most place great 
reliance on it. The fluidextract (Fluidextractum Granati, U. S.) is 
given in the dose of 20 to 30 minims (1.3-2.0). The B. P. contains 
one official preparation of pomegranate— namely, the Decoctum 
Granati Corticis, the dose of which is 1 to 2 fluidounces (30.0-60.0). 



POTASSIUM BITARTRATE 453 

POTASSIUM ACETATE. 

Potassii Acetas, U. S. and B. P., should contain, when thoroughly 
dried, not less than 98 per cent, of pure potassium acetate (KC 2 .H 3 2 ), 
and should be kept in well-stoppered bottles. 

It occurs in a white powder, or in crystalline masses of a satin- 
like luster, odorless, and having a warming, saline taste. It is very 
deliquescent on exposure to the air. 

Soluble in 0.5 part of water, and in 2.9 parts of alcohol at 25° C. 
(77° F.) ; with increasing temperature it becomes much more soluble 
in both liquids. 

It was at one time largely used in the treatment of acute rheu- 
matism in the "alkaline method," as when it enters the blood it is 
changed into an alkaline carbonate. It has been supplanted by the 
salicylates in the treatment of most cases of rheumatism. The dose 
should be from J to 1 ounce (16.0-30.0) a day. A combination of 
10 grains (0.6) of the iodide of potassium and 30 grains (2.0) of 
the acetate is useful in subacute rheumatism in some instances. 

In hepatic torpor acetate of potassium is exceedingly efficacious, 
and aids in promoting the flow of bile as well as that of the urine. 
It has been used in the treatment of the so-called uric-acid diathesis, 
and quickly renders an acid urine alkaline. At one time it was 
supposed to purify the blood by aiding in the oxidation of effete 
material. 

The dose of potassii acetas is from 20 grains to 2 ounces (1.3-60.0), 
the latter dose being employed only when a purgative effect is desired; 
but other drugs are more suitable for this purpose. 

POTASSIUM BICARBONATE. 

This salt (Potassii Bicarbonas, U. S. and B. P.) is used for the 
same purposes as the citrate and acetate of potassium, and, as it is 
much less agreeable in taste, should not be employed when they can 
be obtained. From the bicarbonate of potassium are made several 
very useful preparations: the liquor potassii citratis, by adding 120 
grains (8.0) to 90 grains (6.0) of citric acid and 10 ounces (300.0) of 
water; the neutral mixture, by adding to 1 pint (480.0) of lemon- juice 
enough of the potassium salt to neutralize it. The dose of potassii 
bicarbonas is 5 to 40 grains (0.3-2.6), or even as much as 2 drams 
(8.0) may be given if well diluted with water. 

POTASSIUM BITARTRATE. 

Potassii Bitartras, U. S., Potassii Tartras Acidus, B. P., is some- 
times called "cream of tartar," or acid tartrate of potassium. It is a 
white gritty powder which may occur in rhombic crystals. Owing to 
its stability, it escapes from the body without oxidation, and so 



454 DRUGS 

differs from the other potassium salts formed by vegetable acids 
which are changed into alkaline carbonates. 

Therapeutiqs.— The bitartrate of potassium is the most diuretic of 
the potassium salts, and is used in heart disease with gin or com- 
pound infusion of juniper, for the purpose of removing dropsy. One 
ounce (30.0) of the salt is added to a pint (480 cc) of the infusion 
of juniper berries, and the entire quantity taken in divided doses in 
twenty-four hours. In acute renal disease the drug should be used 
without the juniper and it should be remembered that if nephritis 
prevents the free excretion of the potash it may act as a serious 
depressant. In large doses— J ounce (15.0)— it acts as a watery 
purge, but is rarely so used. Where the urine is thick and alkaline, 
bitartrate of potassium is a useful remedy to acidify and make it 
clear and normal in appearance. 

A useful diuretic beverage called "Imperial Drink" is prepared as 
follows : 

Potassium bitartrate 1 ounce (30.0) 

Tartaric acid 1 ounce (30.0) 

Oil of lemon 12 minims (1.0) 

Sugar 16 ounces 

Boiling water 1 gallon 

Cool and strain. 

POTASSIUM BROMIDE. 

(See Bromide of Potassium.) 

POTASSIUM CARBONATE. 

Carbonate of potassium (Potassii Carbonas, U. S. and B. P.). This 
salt is never used in medicine, except to prepare other salts, as it is 
disagreeable to the taste and is an irritant. (See Potassium Citrate.) 

POTASSIUM CHLORATE. 

Chlorate of potassium (Potassii Chloras, U. S. and B. P.) is a salt 
of potassium differing entirely in its physiological action from all the 
other potassium salts, and, with the exception of the cyanide of potas- 
sium, is certainly the most poisonous. Not only is it, when locally 
applied, an irritant to mucous membranes, but when absorbed into 
the blood in large amounts it causes changes of a serious character 
in this fluid, and produces acute nephritis if given in overdose. 

In dry form chlorate of potassium should never be rubbed with 
organic substances in a mortar, an as explosion may occur. 

Physiological Action.— It has been thought by some that chlorate 
of potassium gives up a large amount of oxygen to the body, and that 
for this reason it would be of value in cases of slow asphyxia, such 
as results from pneumonia or phthisis. It has even been recom- 
mended to travellers crossing high mountains where the rarity of the 



POTASSIUM CHLORATE 455 

air produced disagreeable effects; but nothing is more absurd than the 
belief that it gives up oxygen to the body. Chlorate of potassium does 
give off oxygen when exposed to high heat, but not at the temperature 
of the body. And so small a dose is essential that only an infini- 
tesimal amount of oxygen could be given off. Nearly all of it escapes 
from the body unchanged. 

When overdoses of the chlorate are taken, it produces sickness of 
the stomach, headache, pain in the loins and belly, dyspnea, cyanosis, 
heart-failure, and great weakness. Poisonous doses cause the blood 
to be of a chocolate color, this change being due to the production 
of methemoglobin. The blood-corpuscles are crenated and broken 
down, and after death the liver, kidneys, and spleen are found soft- 
ened and filled with broken-down and disorganized blood. 

Therapeutics.— Chlorate of potassium is useful in stomatitis and in 
mercurial sore mouth as a mouth-wash, or given internally in the 
following mixture : 

1$ — Potassii chloratis gr. xlviij (3.2) 

Tincturse myrrhae f 3ss (2.0) 

Elixiris calisayae q.s. ad fSiij (90.0). — M. 

S. — Teaspoonful (4.0) every five hours, or use as a mouth-wash. 

Owing to the fact that the drug is eliminated by the saliva to a great 
extent, the mucous membranes affected by stomatitis are constantly 
bathed by the solution of the chlorate when it is taken by the stomach. 
If any irritation of the stomach or kidneys exist, the medicament 
must be used on a swab and none of it swallowed. 

In diphtheria chlorate of potassium is very commonly employed, 
but its use is dangerous. Death in many cases of diphtheria is aided 
by renal irritability, possibly by reason of an acute nephritis, and 
this drug simply increases the inflammatory process. If the chlorate 
of potassium is employed in diphtheria, it should be used in solution 
and applied by means of a swab. (See Diphtheria.) 

In acute follicular pharyngitis chlorate of potassium is a useful 
gargle, and Wood recommends the use of a solution made by adding 
1 ounce (30.0) of sumach-berries, J ounce (16.0) of chlorate of potas- 
sium, and 1 pint (480 c c) of boiling water to each other, and allowing 
them to simmer for a few hours, when the mixture should be strained, 
cooled, and used as a gargle. 

The following is equally serviceable: 

1$ — Potassii chloratis 3j (4.0) 

Fluidextracti rhois glabrae f 5ss (16.0) 

Aquae destillatae q. s. ad fSiij (90.0).— M. 

S. — To be added to an equal quantity of water in a glass and used as a gargle every 
two hours, after stirring. 

This prescription makes an abominable-looking pharmaceutical 
preparation, but is an exceedingly useful one. 

In acute rectal catarrh with mucous diarrhea and tenesmus sl solution 



456 DRUGS 

of chlorate of potassium in water, 20 grains (1.3) to the ounce (30.0), 
injected into the bowel, will often produce a cure after one or two 
injections. Not more than 4 ounces (120.0) should be used, and it 
ought to be retained for twenty minutes. Often it will be well to add 
the saturated watery solution of the chlorate to an equal quantity of 
starch-water, as the latter aids in allaying the local irritation. This 
same method can be used in the treatment of hemorrhoids, and a few 
drops of laudanum, if added to this solution, will be found of great 
service. The troches (Trochisci Potassii Chloratis, U. S. and B. P.) 
are given in the dose of 1 to 6, each lozenge containing about 2 J grains 
(0.15). They are intended to be dissolved in the mouth to affect the 
oral mucous membrane, but if many are used they are apt to dis- 
order the stomach and kidneys by reason of an excess of the drug 
being swallowed in the saliva. 

POTASSIUM CITRATE. 

Citrate of potassium (Potassii Citras, U. S. and B. P.) is a white, 
granular, deliquescent salt, almost neutral in reaction and very 
soluble in water. It is by far the most agreeable of all the salts of 
potassium to the taste. In the early stages of bronchitis it is of the 
greatest value when combined with ipecac (see Bronchitis, and it is 
also useful as an alkaline diuretic. In bronchitis the dose should be 
20 grains (1.3) every four hours, and in urinary incontinence due to 
acid and concentrated urine the dose should be equally large. 

Under the name of neutral mixture (Mistura Potassii Citratis), 
made by adding to 1 pint (480 c c) of lemon-juice enough bicarbonate 
of potassium to neutralize it, we have a useful febrifuge drink in 
fevers, particularly those of childhood. The dose is \ to 1 ounce 
(16.0-30.0) every few hours. 

Liquor Potassii Citratis, U. S., is made in the same manner as is 
the neutral mixture, except that citric acid is substituted for the 
lemon-juice (citric acid 6 grams, potassium bicarbonate 8 grams, and 
water 100 cc. 

The neutral mixture is the better preparation of the two, but more 
expensive. A very refreshing and agreeable way of prescribing this 
drug is in the form of "effervescing draught," made by mixing two 
solutions which are prepared as follows: (1) Lemon-juice and water, 
equal parts, enough to make 4 ounces (120 cc). (2) Bicarbonate of 
potassium 1 dram (4.0) and water 3 ounces (90.0). These solutions 
are to be mixed in the quantities desired, and taken while effervescing. 
If lemon- juice is not at hand, a solution of citric acid of the strength 
of 2 drams (8.0) to 4 ounces (120.0) of water should be employed in 
its stead. 

Under the name of Potassii Citras Effervescens the U. S. P. of 
1900 calls for an official powder possessing the advantages of the 
mixture just named. 



POTASSIUM NITRATE 457 



POTASSIUM CYANIDE. 

Cyanide of potassium (no longer official) is used in the same way 
and for the same purpose as hydrocyanic acid. (See Hydrocyanic 
Acid.) The dose is T V to ^ grain (0.006). 

The following prescriptions may be used in cases suffering from 
bronchitis or phthisis accompanied with excessive cough: 

1$ — Potassii cyanidi gr. ij (0.12) 

Morphinae sulphatis gr. j (0.06) 

Syrupi pruni virginianae . . . '. . q. s. ad fSiij (90.0). — M. 

S. — Teaspoonful (4.0) three to five times a day. 

Or as follows : 

1$ — Potassii cyanidi gr. ij (0.12) 

Ammonii chloridi 5ij (8-0) 

Elixir calisayse q. s. ad fSiij (90.0). — M. 

S. — Teaspoonful (4.0) three or four times a day. I do not recommend it. 

POTASSIUM HYDROXIDE. 

Potassium hydroxide (Potassii Hydroxidum; Potassa Caustica, 
B. P.) is a hard white solid, which readily deliquesces; it possesses great 
caustic power, and has been used in medicine for the purpose of burn- 
ing away grotvths or exuberant ulcers. In small cutaneous cancers it is 
applied to the spot for a minute or two after the protecting scab is 
removed. The parts are then poulticed for several days, when the 
slough comes away. A piece of the drug placed on the skin by means 
of a pair of forceps will at once soften and burn the tissues for some 
distance. The surrounding skin should be protected by wax, suet, 
or oils, and a piece of adhesive plaster, with a hole for the growth, 
should first be applied to prevent action on the surrounding healthy 
tissues. The burn produced by caustic potash is very painful, and 
cauterization through its influence should not be practised if it can 
be avoided. When the caustic has acted sufficiently, it is to be 
washed off with vinegar or other dilute acid to neutralize it. It may 
be used in extracting a foreign body from under a nail by scraping 
the nail until it is very thin, then applying a 15 per cent, solution to 
the spot until the nail is soft, washing the part with water. The 
object can then be grasped with forceps. Vienna paste (Potassa 
cum Calce) is used for the same purpose as is caustic potash. 

POTASSIUM IODIDE. 

(See Iodide of Potassium.) 

POTASSIUM NITRATE. 

Nitre (Potassii Nitras, U. S. and B. P.), or saltpetre, occurs in 
long, needle-like crystals and has a sharp, saline taste. Sal prunella 
is saltpetre melted and run into moulds. 



458 DRUGS 

Next to the cyanide and chlorate of potassium, this is the most 
poisonous of the potassium salts, and produces when taken in over- 
dose, violent gastro-enteritis. While it does not affect the blood, it 
is more irritant than the chlorate. 

Nitrate of potassium is rarely employed at present, and has been 
very properly put aside as inferior to the harmless vegetable potas- 
sium salts (the citrate, acetate, and bitartrate). If used in rheuma- 
tism, the dose should be 1 ounce (30.0) in a pint (480 cc) of barley- 
water or syrup of acacia and water, to be taken in divided doses 
of a tablespoonful every three hours. Nitrate-of -potassium papers 
(Charta Potassii Nitratis) are made by dipping unsized paper in a 
solution of the drug of the strength of 20 parts of the salt to 80 parts 
of distilled water. They are rolled into cigarettes and smoked by 
asthmatics, or burned in a pan and the fumes arising from them 
inhaled. Their efficacy may be increased in cases where the respira- 
tory mucous membrane is irritable by dipping them in compound 
tincture of benzoin and exposing to the air long enough to dry. They 
should then be protected from the air until used. The paper used 
should be moderately thin bibulous paper. 

PROCAINE. 

Procaine, German name novocaine, is a synthetic chemical, being 
the hydrochloride of para-amino-benzoyl-diethylamino-ethanol. It is 
a colorless crystalline substance, soluble in equal parts of water, and 
is not damaged by boiling. 

Physiological Action.— Procaine paralyzes peripheral sensory nerves 
as does cocaine, but is not so irritant, although its benumbing effects 
are as marked as that drug. Experiments on animals indicate that 
it is about one-seventh as toxic as cocaine and one-third as toxic as 
eucaine. Dropped into the eye it does not cause mydriasis. 

Therapeutics.— The sole use of procaine is to produce anesthesia 
either by topical application, infiltration, or by spinal anesthesia. 
Many surgeons regard it as the anesthetic of choice for these purposes. 
In the eye the strength of the solution varies from 1 to 10 per cent. 
For infiltration anesthesia, where large areas are to be affected, a \ 
of 1 per cent. (0.25) may be employed, and for intraspinal anesthesia 
2 to 3 c c of a 5 per cent, solution is to be used, combined, as a rule, 
with adrenalin or the synthetic product, suprarenin. When used in 
the nose the solution is usually of the strength of 5 per cent., and when 
employed in the throat the solution may be 10 to 15 per cent. When 
used as an anesthetic to the gastric mucosa the dose is said to be from 
2 to 7 grains (0.01-0.5). The best way to use it is in the tablets of 
procaine and sodium chloride, prepared by the manufacturers for the 
preparation of solutions. 

The method of inducing spinal anesthesia is as follows: If the 
patient is strong he sits on the edge of the operating-table, with his 



PROCAINE 459 

feet on a chair and with his body bent forward as far as possible to 
separate the intervertebral spaces. If the patient is too feeble to 
sit up, or there are other reasons for the prone posture, he lies on his 
side with the back flexed and the knees drawn up as far as possible. 
The skin from the first to the last lumbar vertebra is sterilized with 
tincture of iodine, and it may be anesthetized by Schleich's infiltration 
method. (See Cocaine.) A strong hollow needle, reinforced by a 
stylet in some cases, is then introduced a little to one side of the 
middle line at different levels according to the area it is desired to 
anesthetize, but never above the tenth dorsal interspace, as there is 
danger of injuring the cord. It usually enters the subarachnoid 
space at a depth of 4 to 6 Cm., according to the size of the patient. 
When introduced in the lumbar region the direction of the needle is 
almost at a right angle to the plane of the back, but directed slightly 




Fig. 64. — A, space between the third and fourth lumbar vertebrae for subarachnoidean 
injection (Quincke's area) ; B, area of puncture suggested by Turner. 

upward. In the dorsal region this upward tendency is increased so 
as to conform to the overlapping of the spinous processes. If the 
puncture is successful on withdrawing the stylet, cerebrospinal fluid 
escapes from the needle in drops or jets. If the tap is dry the needle 
may be plugged by tissues, it may have failed to enter the space, or 
it may have been carried across the space and be embedded on the 
other side. The re-introduction of the stylet may remedy the first 
fault, pushing the needle farther may correct the second difficulty or, 
withdrawing it, may disengage the tip from the tissues on the far 
side from the puncture. If these moves fail another puncture must 
be made. If the needle is dripping fluid a syringe is attached to 
it, and a little cerebrospinal fluid is sucked into it to warm the 
syringe and to dilute the contents of the procaine solution which 
has been drawn up into the syringe. The injection should be slowly 
made. When the area to be anesthetized is that of the lower limbs 



460 DRUGS 

and trunk up to the navel the injection is made at the third or 
fourth lumbar level, and this area can be increased to the nipple 
by tilting the body so that the fluid is diffused upward. When the 
upper abdominal area is to be anesthetized the tenth or eleventh 
dorsal space is selected. A good localizing point is made by drawing 
a line across the back from the iliac crests. This corresponds to the 
space between the third and fourth lumbar vertebrae. Within a few 
moments the legs feel asleep and numb and the patient is ready for 
operation almost at once. The site of operation is shut off from 
vision by a hanging sheet. 

If the patient is very apprehensive a hypodermic injection of 
scopolamine and morphine may be given before the puncture is 
made. Severe headache lasting for days is the most common unto- 
ward effect. Vomiting seems to occur in about 7 per cent, of cases. 
Age does not seem to contraindicate the method at either extreme of 
life. Apparently, it is not contraindicated as strongly as ether or 
chloroform when the heart, lungs, or kidneys are diseased or when 
diabetes is present. Indeed, it seems safer than these drugs in pro- 
found asthenia. The patient should rest in bed for several days after 
the injection. 

Notwithstanding the claims of its advocates, spinal anesthesia is 
not very widely practised. It is statistically more dangerous than 
chloroform, for in 15,842 cases collected by Strauss there were 21 
deaths, or 1 in 754. Miller states that in 35,062 cases there were 68 
deaths or 1 in 515. These statistics represent all the drugs so used, 
not procaine alone, which latter is safer than others. The method 
is to be used in certain peculiar cases, but not as a general procedure. 

PROTARGOL. 

Protargol is a new silver preparation containing 8.3 per cent, of 
silver, and occurs as a yellowish powder readily dissolved in cold and 
hot water, forming a clear solution. It is employed in gonorrhea and 
in gonorrheal conjunctivitis because it is destructive to the gonococcus. 
(See Conjunctivitis.) It is not precipitated on contact with albumin 
or alkalies, nor by dilute hydrochloric acid. It therefore has distinct 
advantages over nitrate of silver. A 1 to 5 per cent, solution of pro- 
targol is the strength ordinarily used in the treatment of gonorrhea, 
and these solutions may also be employed in the eye. (See Conjunc- 
tivitis.) If used on a camel' s-hair brush or swab, the solution may be 
as strong as 5 per cent.; but if the drug is used as a collyrium its 
strength should not exceed 1 : 400 or 1 : 200. 

PRUNUS VIRGINIANA. 

Prunus Virginiana, U. S., and Pruni Virginians Cortex, B. P.— 
wild cherry, as it is incorrectly called— is the bark of Prunus sero- 



QUASSIA 461 

Una, a large tree of the United States and Canada. It contains a 
substance known as amygdalin, which when it comes in contact with 
water forms hydrocyanic acid through the action of another substance, 
known as emulsin. 

Therapeutics.— Wild-cherry bark is largely used as a domestic tonic, 
and in the form of a syrup as a vehicle for cough mixtures. 

It has been supposed that the hydrocyanic acid present allays the 
cough, but this is doubtful, as the acid is fleeting in its effect and is 
present in very small quantity. 

Administration.— As a tonic prunus virginiana is used in the form 
of the infusion, dose J to 1 ounce (16.0-30.0), and the fluidextract, 
dose 30 minims to 1 dram (2.0-4.0). The syrup (Syrupus Pruni 
VirginianoB, U. S. and B. P.) is given in the dose of 1 to 4 drams 
(4.0-16.0), § to 1 fluidram (2.0-4.0), B. P. The B. P. also contains 
a tincture (Tinctura Pruni Virginians), given in the dose of \ to 1 
dram (2.0-4.0). 

PYOKTANIN. 

(See Methyl Blue.) 

PYROGALLOL. 

Pyrogallol, U. S., sometimes called pyrogallic acid, is a triatomic 
phenol obtained by carefully heating gallic acid, and should be kept 
in dark, well-stoppered bottles. It occurs in light white scales or 
crystals, has no odor, but a bitter taste. If exposed to the light, it 
becomes dark. It is soluble in 1.7 parts of water, 1.6 ether and 1.3 
alcohol. 

Therapeutics.— Pyrogallol is used in parasitic skin diseases, in oint- 
ment, in the strength of 30 to 100 grains (2.0-6.6) to the ounce (30.0). 
The stronger ointments exercise a mild caustic effect. It may be 
employed in place of chrysarobin in psoriasis. It stains the skin a 
deep brown. 

QUASSIA. 

Quassia, U. S. (Quassia? Lignum, B. P.) is the wood of Picrasma 
excelsa, a large tree of Jamaica and other islands of the West Indian 
group. It is also derived from Quassia amara. It contains an active 
principle, named quassin, which is intensely bitter and an irritant to 
mucous membranes. 

Quassia is a simple bitter tonic which has been used very largely in 
domestic medicine and by the medical profession. It is very efficient 
as a tonic, is supposed to be particularly useful in the anorexia follow- 
ing malarial fevers, and has even been thought to possess antiperiodic 
power. In simple dyspepsia with eructations after meals, due to 
gastric inactivity, it is very serviceable. 

In the treatment of seat-worms (Oxyuris vermicularis) , or thread- 
worms, as they are often called, injections of the infusion of quassia 



462 DRUGS 

are the most efficacious and useful remedial measures we possess, and 
yet are harmless to the patient. The bowel should be well washed 
out with soap and water, and \ pint to 1 pint of an infusion, made 
by adding 1 to 2 ounces (30.0-60.0) of quassia chips to a pint (480) 
of water, should be injected and retained for some minutes. A few 
such injections will invariably kill the parasites, provided the bowel is 
first well washed out with soap and water and enough fluid is injected 
to reach high up into the rectum. 

Administration.— The tincture (Tinctura Quassia, U. S. and B. P.) 
is given in the dose of J to 1 dram (2.0-4.0), the nuidextract \ dram 
(2.0), and solid extract 1 to 3 grains (0.06-0.2). The infusion (In- 
fusion Quassias, B. P.) is given in the dose of J to 1 ounce (16.0-30.0), 
and is made by macerating 10 grams of quassia with 1000 cc of 
water, and allowing it to stand fifteen minutes or more. 

QUERCUS. 

Quercus, or white oak, in infusion made from the crude drug 1 
ounce (30.0) to the pint (480 cc), or by adding the fluidextract to 
water, is used as an astringent injection in gonorrhea and vaginitis in 
women, where a large amount of fluid is necessarily employed. It 
is also used in prolapse of the rectum, in hemorrhoids, in leucorrhea, 
and as a gargle in sore-throat. It stains the clothing very slightly. 

Quercus Tinctoria is equally efficient, but is seldom used because 
it stains the clothing. In the form of the powdered bark it is often 
used as an astringent poultice to freely running sores, to check the 
discharge. 

RESIN, OR ROSIN. 

Resina, U. S. and B. P., is resin or rosin, the mass left after the 
distillation of turpentine, and enters largely into plasters, cerates, and 
similar preparations. Its fumes when it is burnt are said to be of 
value when inhaled in cases of chronic bronchitis. Ceratum Resina, 
U. S., is used in chilblains and superficial scalds. Ceratum Resina 
Compositum, U. S., popularly known as Deshler's Salve, is used as a 
stimulating application. Unguentum Resina is a B. P. preparation, 
and is used for the same purposes as the cerate. 

RESORCINOL. 

Resorcinol, U. S., and Resorcinum, B. P (metadioxybenzol), is the 
meta-compound of the group of which hydrochinone is the para- and 
pyrocatechin the ortho-, and occurs in clear crystals of a slightly 
reddish hue. It is quite soluble in water, alcohol, and ether. 

Physiological Action.— Resorcinol is an irritant to mucous mem- 
branes, and when taken internally in poisonous doses causes deafness, 
giddiness, salivation, profuse sweat, unconsciousness, and clonic con- 



RESORCINOL 463 

vulsions. The heart of the dog under its influence is at first slowed 
by vagal stimulation, and then becomes very rapid in its action from 
vagal palsy. 

Therapeutics.— Resorcinol has been found of service as a remedy for 
whooping-cough, given in the dose of 10 minims (0.6) of a 2 per cent, 
solution or used in a spray of the same strength, the latter being the 
better method of using the drug. 

Resorcinol has also been employed in a spray in 2 per cent, solution 
in hay fever with remarkably good effects. It has been used as an 
antipyretic, but is not serviceable and has little power over fevers. 

The chief use of resorcinol is in skin affections of a subacute or 
chronic character, such as eczema with much induration, and in 
psoriasis. In these states an ointment of the following character, 
well applied, is of service: 

1$ — Resorcinolis 5J (4.0) 

Zinci oxidi 3J (4.0) 

Unguenti aquae rosse 5x (40.0). — M. 

S. — Apply twice a day to the part affected. 
After mixing the ointment heat it until the resorcinol crystals melt, to prevent 
any irritation of the skin. 

Resorcinol is also of service in weak solution in allaying itching of 
the skin due to erythematous eczema. For this purpose it should be 
used in watery solutions of about 10 or 15 grains to the ounce, and a 
little salt added to aid in its absorption by the skin. This should be 
dabbed, not rubbed, on the part : 

1$ — Resorcinolis gr. xv (1.0) 

Glycerini TRx (0.6) 

Liquoris calcis f5j (30.0).— M. 

In the slowly spreading epithelioma of the face the following plaster, 
recommended by Hartzell, is useful : 

1$ — Resorcinolis . gr. lxxij (5.0) 

Cerse flavi et pulveris resinse 5iss (6.0) 

Olei olivse q. s. — M. 

Another valuable use of resorcinol is in the treatment of seborrhea 
capitis of the dry, scaly type: 

1$ — Resorcinolis 5J (4.0) 

Olei ricini ITlxxx (2.0) 

Alcoholis f5ij (60.0) 

Spiritus myrcise q. s. f5iv (120.0). — M. 

S. — Use as a lotion to the scalp, after washing with castile soap and water, once a 
day. 

Within the last few years resorcinol has been employed with good 
results in the treatment of gastric ulcer in the dose of 2 to 4 grains 
(0.12-0.25) before each meal in pill or capsule. It is supposed to act 
by reason of its analgesic, antiseptic, and hemostatic power. 



464 DRUGS . 

RHAMNUS PURSHIANA. 

(See Cascara Sagrada.) 

RHIGOLENE. 

Rhigolene is a product of petroleum obtained by repeated redistilla- 
tion until the liquid resulting from this process boils at 64.4° F. It 
evaporates more rapidly than any other known liquid, except cymo- 
gene, which boils at 32° F., and is used in a spray for the production 
of localized numbness or freezing before minor painful operations. 

RHUBARB. 

Rheum, U. S. (Rhei Radix, B. P.), is the root of several species of 
Rheum, a plant of Thibet, but which is cultivated in America and 
elsewhere. It is also derived from China, and this variety is known as 
Chinese rhubarb. Several alkaloids are contained in it, all of which 
are unimportant and never used alone, except chrysophanic acid. 

Physiological Action.— According to the studies of Prevost and 
Binet, rhubarb acts inconstantly upon the flow of bile, sometimes 
increasing it, sometimes having no effect; but, on the other hand, 
according to those of Rutherford and Vignal, it never fails to stimu- 
late biliary secretion. Owing to the astringent properties possessed 
by rhubarb, it does not purge excessively, and improves the appetite, 
digestion, and intestinal tone. Its constant use produces chronic 
constipation. 

Therapeutics.— Whenever it is desired simply to unload the bowels 
without affecting the general system rhubarb may be employed. 
With equal parts of castor oil it is very effective. In children a state 
is very commonly seen in which constipation is replaced by diarrhea if 
any ordinary laxative is employed, and in these instances rhubarb is 
the best remedy, as it is astringent and prevents any after-effects 
other than those directly produced by the dose. In the summer 
diarrhea of children, when the stools are green, rhubarb is often used 
to empty the bowels of fermentative products before direct treatment 
is instituted. 

Rhubarb, because of its chrysophan, may stain alkaline urine 
carmine or acid urine yellow. 

Administration.— The preparations of rhubarb are unnecessarily 
numerous. Rhubarb itself may be given in the dose of 20 grains 
(1.3) in powder, and small pieces of the root are habitually chewed 
by some persons for the relief of constipation. Extractum Rhei, 
U. S. and B. P., is given in the dose of 5 to 10 grains (0.3-0.6) in pills. 
Pilula? Rhei, U. S., of which each pill contains 3 grains (0.2) of rhu- 
barb, is given in the dose of one to three pills; and Pilula? Rhei 
Composite, U. S., and Composita, B. P., which contain 2 grains (0.12) 
of rhubarb and 1J (0.09) of aloes, are given in the same dose. Pubis 



ROSA GALLIC A ■ 465 

Rhei Compositus, U. S. and B. P., contains rhubarb, magnesium oxide, 
and ginger, and is given in the dose of 20 to 40 grains (1.3-2.6) ; Fluid- 
extractum Rhei, U. S., is given in the dose of 20 to 30 minims (1.3-2.0). 
Synqms Rhei, U. S. and B. P., is given in the dose of 1 dram (4.0) 
to a babe, and 4 drams (16.0) to an adult, although rarely used for 
older persons. Synqms Rhei Aromaticus, U. S., is given in the same 
dose and to the same class of cases. Tinctura Rhei, U. S., is used in 
the dose of \ to 2 drams (2.0-4.0), Tinctura Rhei Aromatica, U. S., 
Tinctura Rhei Composita, B. P., is used in the dose of J to 1 dram 
(2.0-4.0), and Tinctura Rhei Dulcis, U, S., 2 to 3 drams (8.0-12.0). 
The aromatic syrup is commonly employed for children, and the 
compound pills for adults. Infusum Rhei, B. P., is given in the dose 
of 1 to 2 ounces (30.0-60.0). 

RHUS AROMATICA. 

Sweet sumac is unofficial, but has been so largely used of late that 
it deserves notice. In hematuria, Menorrhagia, diabetes insipidus, 
and in urinary incontinence in children depending upon vesical atony 
it has been highly praised. In the latter affection a sufficient amount 
of experience has been acquired to show that it really is of benefit. 
Rhus aromatica should be used in the form of the fluidextract, derived 
from the bark of the roots according to the general directions in the 
Pharmacopoeia for making fluidextracts. The dose as a remedy for 
urinary incontinence is 15 minims (1.0) of this preparation. Adults 
may take from 15 to 60 minims (1.0-4.0). The drug is best given 
with glycerin and water. 

RHUS GLABRA. 

Rhus Glabra, smooth sumac, is the fruit of Rhus glabra, and con- 
tains tannic and malic acids as its chief constituents of medicinal 
value. In the fluidextract we have a preparation which is very 
efficient as a gargle for sore-throat when diluted with glycerin and 
water or prepared according to the formula given under Potassium 
Chlorate. 

ROCHELLE SALT. 

Potassii et Sodii Tartras, U. S. (Soda Tartarata, B. P.), is largely 
used as a saline cathartic in the dose of \ ounce (16.0), and is pre- 
ferred by many patients to Epsom salt because its taste is not so 
disagreeable. It is, however, more irritating. Rochelle salt is the 
purgative constituent of Seidlitz powder. 

ROSA GALLICA. 

Rosa Gallica, U. S. (Rosa? Gallic^ Retala, B. P.), red rose, con- 
tains gallic and tannic acids, and is astringent. From it are pre- 
30 



466 DRUGS 

pared the Fluidextractum Rosce, U. S., dose 5 drops to 2 drams 
(0.3-8.0), used to flavor other extracts, and the Confectio Rosce, 
U. S., and Confectio Rosce Gallicce, B. P., which are used as bases for 
pills. Mel Rosce, U. S., or honey of rose, is employed as a local 
application or as vehicle for gargles, and the Syrupus Rosce, U. S. 
and B. P., dose 1 to 2 drams (4.0-8.0), as a flavoring substance. 
The acid infusion (Infusum Rosce Acidum, B. P.) is given in the dose 
of J to 1 fluidounce (15.0-30.0). 

Aqua Rosce, U. S. and B. P., is used as a diluent or solvent for 
preparations, such as astringents, which are to be employed locally, 
as in injections for gonorrhea. It may also be used internally for 
these purposes. Unguentum Aquce Rosce, U. S. and B. P., is "cold 
cream," and is largely used as an emollient application to small 
burns, sores, cuts, scratches, and chapped hands and lips. It is much 
improved if a little glycerin and benzoic acid are added to keep it 
sweet in warm weather. 



RUBUS ID2EUS, OR RASPBERRY. 

Rubus IdaBus, or raspberry, is used for the preparation of a syrup 
(Syrupus Rubi Idcei), which is employed very largely as an elegant 
vehicle or flavoring mixture. The leaves are often used in domestic 
medicine in a decoction or infusion for the cure of diarrhea when an 
astringent is needed. 

RUE. 

Ruta graveolens is the source from which is derived the oil of rue. 

Physiological Action.— Locally applied, rue is an irritant, producing 
vesication, and if taken internally in large amount gastro-enteritis, 
which may be very severe. It is eliminated by the lungs, kidneys, 
and skin, and its odor is easily recognized in all these secretions. If 
the dose be poisonous, vomiting, great pain in the belly, and epilepti- 
form convulsions come on, but death has rarely occurred. 

Therapeutics.— Rue has been used as an abortifacient, but with 
great danger to the mother. Its action is most uncertain even when 
poisonous doses are employed. It has been given in colic as a car- 
minative, and seems to be valuable in atonic menorrhagia and metror- 
rhagia. - N 

Oil of rue has been employed for the removal of lumbricoid or 
round-worms, but should not be so used. The dose of the oil is 3 
to 6 minims (0.2-0.4), best given in capsule. 

SACCHARIN. 

Saccharin (Benzosulphinidum, U. S.; Glusidum, B. P.) is the anhy- 
dride of ortho-sulphamide-benzoic acid or benzoyl-sulphonic-imide. 
It occurs as a white, crystalline powder, nearly odorless, having an 



SALICYLATE OF SODIUM 467 

intensely sweet taste even in dilute solutions. It is soluble in 290 
parts of water and in 31 parts of alcohol, and but slightly soluble in 
ether or chloroform at 25° C. (77° F.) ; soluble in 25 parts of water at 
100° C. (212° F.). This compound was first prepared by Fahlberg, 
under the direction of Professor Remsen, of Johns Hopkins University. 
It is a remarkably sweet substance, two hundred and twenty times 
stronger than sugar in sweetening power. It is used largely to sweeten 
glucose and in confections. Saccharin escapes from the body 
unchanged, and is used in place of sugar to sweeten coffee, food, or 
medicine in cases of diabetes and govt. 

The dose is indefinite, but it is to be noted that a very few grains 
will sweeten a large bulk of material. As 1 grain (0.06) is equiva- 
lent to about 1 teaspoonful (4.0) of sugar, less than 1 grain is the 
quantity usually given. It is commonly sold in small tablets contain- 
ing half a grain each (0.03). 

Physiological Action.— Upon the circulation and similar vital func- 
tions saccharin has no effect, but Plii gge has proved it to retard the 
action of all the digestive ferments, and to be in consequence not 
devoid of evil effect on diabetics whose digestion is impaired. Never- 
theless the general idea that it is harmful in ordinary amounts is 
incorrect 

SALICIN. 

Salicin (Salicimim, U. S. and B. P.) is a glucoside obtained 
from several species of Salix and Populus. In other words, it is 
obtained from willow-bark. It is crystalline, without odor, and quite 
bitter, and is soluble in 23.5 parts of water and 88.4 of alcohol at 25° C. 
(77° F.) . Salicin is highly thought of by many practitioners as a sub- 
stitute for salicylic acid in the treatment of acute articular and muscu- 
lar rheumatism. It has also been largely used in the treatment of 
influenza. The dose is from 5 to 40 grains (0.3-2.6) every four hours, 
and it is best given in capsule or cachet, and washed down with a 
draught of water or milk after food has been taken. 

SALICYLATE OF ETHYL. 

Ethyl salicylate, sometimes called "Sal Ethyl" {Mtliylis Salicylas), 
has the same action as the other salicylates, but is said to be less prone 
to produce disagreeable effects. It occurs as a colorless, volatile 
liquid, of pleasant aromatic taste, and is given in capsules in the dose 
of ^5-10 minims (0.3-0.6 cc), as may be indicated. 

SALICYLATE OF METHYL. 

(See Gaultheria.) 

SALICYLATE OF SODIUM. 

Salicylate of sodium (Sodii Salicylas, U. S. and B. P.) is a less 
irritant and somewhat less disagreeable preparation than salicylic acid. 



468 DRUGS 

Its internal action, use, and doses are the same as those of the acid. 
It may be given by dissolving it in milk, and then adding rennet to 
produce a curd, which disguises the taste and protects the stomach. 
It is very soluble in water. 

Other salicylates are largely used by some practitioners. Salicylate 
of lithium is supposed by some physicians to be of more value than 
the other salts. (See Aspirin, Strontium, and Salophen.) 

SALICYLIC ACID. 

Salicylic acid (Acidum Salicylicum, U. S. and B. P.) occurs in 
fine white crystals or in fine white powder. It has a sweet yet acrid 
taste, and is derived from carbolic acid by treating it with caustic 
soda and carbonic acid at a moderate heat. Sometimes it is derived 
from plants in which it exists in combination, although the artificial 
acid is chiefly used. If the crystals are pinkish in hue, the acid should 
not be used, as it is probably impure. It is soluble in 460 parts of 
water and 2.7 parts of alcohol at 25° C. (77° F.). 

Physiological Action.— On mucous membranes salicylic acid acts as 
an irritant. (See Poisoning.) 

Nervous System.— Upon the nervous system salicylic acid exerts 
a moderate influence when given in medicinal doses, and causes 
buzzing in the ears and decrease of the reflexes. In poisonous doses 
epileptiform convulsions are produced by an action on the brain. 

Circulation.— Upon the circulation the effects of salicylic acid 
are not very marked in medicinal dose. It undoubtedly has a depress- 
ant rather than a stimulant effect, but the depression is very slight. 
It is sufficient, however, to make the use of the drug in massive doses 
in cases of feeble circulation worthy of thought and care. 

Respiration.— Salicylic acid feebly stimulates the pulmonary vagi 
and respiratory center, but if the dose be poisonous death is due 
to respiratory failure. Medicinally it does not affect this function. 

Temperature.— The effect of salicylic acid on temperature has 
been studied by the author with a good deal of care. The drug acts 
as a distinct antipyretic upon fevered states, and is a slight depressant 
of normal bodily heat. The studies of Gedl, Furbringer, and See 
also show this, and those of Danewsky point to it. In the experi- 
ments of North upon man, after and during exercise, the antipyretic 
effects were marked. According to the author's studies, the drug 
lowers fever by diminishing heat-production and increasing heat- 
dissipation, but this is by no means positively decided as a fact. 

Absorption and Elimination.— Salicylic acid is absorbed from 
the stomach as a salicylate of sodium, and so circulates in the blood. 
It is eliminated by the kidneys and by all the secretions. In the urine 
it appears as salicyluric acid. According to Kolbe, after a dose of 1 
ounce (30.0) elimination does not commence for three hours, but 
Fleischer found the drug in the urine in one and a half hours. Usually, 



SALICYLIC ACID 469 

however, it is far more rapidly eliminated, and, as pointed out by 
Soullier, after a dose of 15 grains (1.0) it appears in the urine in ten 
to twenty minutes and after 30 grains (2.0) in five minutes. The 
elimination continues for a period of from thirty-three to fifty-six 
hours (Weill). The urine after very large doses is dark olive green, 
and this change in color is due to the presence of indican and pyro- 
catechin, which are formed by the action of the pancreatic juices upon 
the drug in the intestine. The presence of salicyluric acid in the 
urine is to be discovered by the addition of a solution of the chloride 
of iron to that fluid, which causes the appearance of a violet color. 
Stockman has shown that salicyluric acid is inert, so the drug prob- 
ably acts as salicylate of sodium. 

The increase in the elimination of uric acid when salicylic acid is 
given is not due so much to an increase in the excretion of acid already 
formed, but is due to increased metabolism or tissue change produced 
by the drug. That the drug does not increase the elimination of the 
uric acid already deposited in the tissues is also proved by the fact that 
the salicylic acid and not salicyluric acid is often found in the kidney. 
Poisoning.— Salicylic acid when taken in excessive dose causes 
profuse sweating, roaring in the ears, dimness of vision, headache, 
partial or total deafness, and a decided fall in temperature. The 
pulse becomes weak and relaxed, and finally ptosis, strabismus, and 
general paralysis ensue. The urine and feces are passed involun- 
tarily, and the urine is olive green in color. The respirations at first 
are quickened and deepened, but finally become shallow and feeble, 
death ensuing from respiratory failure. 

If the dose is sufficiently large, the blood is involved and the cor- 
puscles rapidly break down. 

Therapeutics.— Salicylic acid, owing to its close resemblance to 
quinine, was first introduced as an antiperiodic and antipyretic, but 
soon was found to be of inferior value in these states and of super- 
lative value in acute articular rheumatism, in which disease it is 
supposed to destroy the specific microorganism. 

At present it is rarely if ever used for either of the former pur- 
poses, but is largely employed as a standard remedy for the latter 
disease. (See Rheumatism.) 

The value of salicylic acid in rheumatism limits itself solely to 
the relief of pain and the cure of the malady without preventing the 
complications incident to its course. That is to say, the changes in 
the joints or heart in rheumatism are only of less frequency after the 
use of salicylic acid because the drug shortens the disease, and not 
because it prevents these changes by a direct influence; this is also 
true of rheumatic hyperpyrexia, where salicylic acid is of service in 
shortening the attack, though it often fails to control the temperature 
to any great extent. In acute rheumatism 15 to 20 grains (1.0-1.3) 
should be given every four hours until marked physiological symptoms 
occur. With these doses it is wise to give 10 to 15 grains (0.6-1.0) 



470 DRUGS 

of sodium bicarbonate to prevent irritation of the stomach and because 
clinical experience has shown that this combination acts better for 
the cure of the disease than the salicylates alone. When larger doses 
are used the sodium bicarbonate tends to prevent the development of 
coma associated with acetonuria. Another method is to give 30 or 
40 grains at 5 and 7 p.m., with a copious draught of milk, so that the 
main effects will be produced during sleep. If a cure does take place, 
relapses are very common indeed, and the drug should always be 
continued for many days after all symptoms cease. If the use of 
full doses of the salicylates fail to produce results after four or five 
days the probabilities are that the case is not one of true rheumatic 
fever but an arthritis due to another infection. The tonsils, teeth 
and genito-urinary tract should be carefully looked into as a focus of 
infection. (See Rheumatism.) 

When chorea is associated with rheumatism it is a better drug 
than arsenic. In gonorrheal rheumatism salicylic acid is of no value, 
for it has no influence upon the gonococcus in the joints. In rheu- 
matoid arthritis it is valueless except to possibly relieve pain. 

The question as to the value of the salicylates in cases of gout is 
one open for debate. Some physicians regard it as useful, others 
as useless. Thus Duckworth states that in his experience and 
that of his friends the salicylates do not compare with colchicum. 
On the other hand, See, Jaccound, and Haig find them useful. If 
they are of any value, it is only when the dose is very large, and even 
then their usefulness seems to be doubtful. In that systemic state 
sometimes called "lithemic" the salicylates are useful. In subacute 
rheumatism citrate or acetate of potassium may be used in place of 
salicylic acid in the dose of 30 to 60 grains (2.0-4.0), these salts 
being taken just before going to bed. 

In lumbago, sciatica, and similar states salicylic acid is a very 
useful remedy. While it is not so good as phenacetin in neuralgia, it 
is of great service in the migraine of rheumatic persons, often curing 
the attack. (See article on Migraine.) 

Brunton has highly recommended the use of the salicylates with 
the bromides in the nervous irritability of gouty or lithemic persons. 

Salicylic acid has been largely used for the removal of pleural effu- 
sion if the effusion be serous. Dock believes that the duration of 
treatment is less with the salicylates than by the use of diuretics, 
alteratives, or purgatives, but the author has not reached good results 
from this plan of treatment. The dose should be from 1 to 2 drams 
(4.0-8.0) daily. Doses larger than this are not necessary. How sali- 
cylic acid does good in pleural effusion is not known, as its diuretic 
properties are not sufficiently great to drain away the liquid by this 
means. 

In quinsy or true tonsillitis the drug is thought by some practitioners 
to act as a specific, particularly when this condition is associated with 
a rheumatic tendency or goutiness. It will often prevent suppuration, 



SALICYLIC ACID 471 

shorten the attack, and relieve the pain and swelling. The doses 
should be small, say 3 grains (0.2) at each dose, and given hourly. 
In stomatitis, after the blisters have broken, the burning and pain are 
often intense, and a mouth-wash of salicylic acid in the proportion of 
1 to 250 of water is useful. 

Ringer recommended the use of the following salve in 'pruritus of 
the anus and vulva: 

]$ — Acidi salicylici 5ij (8.0) 

Olei theobromatis . .' 3v (20.0) 

Cetacese 3iij (12.0) 

Olei myristicae f 5iss (6.0). — M. 

In the treatment of corns there is probably no better'application 
than lint soaked in a solution of salicylic acid, or the use of the follow- 
ing formula as a paint, which should be applied after soaking the foot 
in hot water: 

1$ — Acidi salicylici gr. xxx (2.0) 

Extracti cannabis . . . gr. v (0.3) 

Collodii f5ss (16.0).— M. 

S. — Apply with a brush until a good coat is formed. 

After a few days the corn can be peeled off with ease. 
A useful salve for the soreness following horseback or bicycle riding 
is one composed as follows : 

]$ — Acidi salicylici gr. x (0.6) 

Adipi benzoinatis Sj (30.0). — M. 

S. — Apply to the sore part. 

A solution of salicylate of sodium or of bicarbonate of sodium, 
applied on lint to inflamed rheumatic joints, often gives great relief. 
Smearing an ointment of salicylic acid over the joints not only pro- 
duces good effects locally, but by absorption of the drug influences 
the disease. (See Rheumatism, Part IV.) 

In gastric dilatation or catarrh, where vomiting occurs and the 
matters vomited contain sarcince, salicylic acid will be found of ser- 
vice, as it acts as an antiseptic in the stomach. In adults suffering 
from ascaris lumbricoides , or round-worms, salicylic acid may be used 
in the dose of 8 grains (0.5) every hour till 40 grains (2.6) are taken. 
This treatment should be followed by the use of a purge. For thread- 
or seat- worms the following injection will be found of service : 

]$ — Acidi salicylici 3ss (2.0) 

Sodii boratis 3ss (2.0) 

Aquae Oj (480).— M. 

S. — Warm, and inject into the bowels. For a child reduce this one-half in all its 
parts. 



472 DRUGS 

In bromidrosis of the feet (excessive sweating with fetor) salicylic 
acid may be dusted over the parts, or the following powder used : 

1$ — Acidi salicylici, 

Pulveris amyli aa 5ss (16.0). — M. 

S. — Apply to the feet. 

In eczema of the face and hands, where the eczema is of the wet or 
weeping variety, salicylic acid, locally applied, is often of great service. 

1$ — Acidi salicylici gr. v vel x (0.3-0.6) 

Pulveris amyli 3ij (8.0) 

Pulveris zinci oxidi 5ij (8.0 

Petrolati 5ss (16.0).— M. 

S. — Apply locally. 

If the eczematous process is subacute and needs stimulation, the 
salicylic acid may be increased to 20 or 30 grains (1.3-2.0). 

Antiseptic Use.— Salicylic acid is employed as an antiseptic in the 
treatment of wounds as a local remedy and as a dressing, but should 
not be applied over too large an area, as it may be absorbed and pro- 
duce constitutional symptoms. As an application to small burns a 
mixture of 1 dram (4.0) of salicylic acid to 8 ounces (240.0) of olive 
oil is of service. 

In the treatment of soft chancres and venereal sores salicylic acid 
has been largely used by some practitioners either as a salve or as a 
dusting-powder, as follows : 

I^ — Acidi salicylici gr. xx (1.3) 

Alcoholis gtt. xlv (3.0) 

Adipis benzoinati §ij (60.0). — M. 

Or, 

1$ — Acidi salicylici gr. xv (1.0) 

Pulveris amyli vel cretse 5ij (8.0). — M. 

Salicylic acid may be added to urine to prevent its decomposition, 
but will sometimes cause the reactions for sugar to appear. Patients 
taking salicylic acid often notice that the urine is odorless after stand- 
ing, and that it will remain fresh for many days because of the salicy- 
luric acid present in it. The drug may cause, when taken internally, 
the reaction of sugar in the urine with Trommer's test. 

Untoward Effects.— Salicylic acid, as already stated, may produce 
headache and roaring sounds in the ears. In persons with middle-ear 
disease it is contraindicated unless urgently called for, as it often 
makes the deafness permanently worse. Sometimes erythema or 
acne follows its employment, and blindness and retinal hemorrhages 
have occurred. Striimpell asserts that delirium of an active character 
sometimes appears after full doses of salicylic acid, which delirium is 
usually happy in its type, and is seen most commonly in young girls. 
Sometimes full doses produce visions which may be seen only when 
the eyelids are closed. When very large doses are given symptoms 
resembling diabetic coma may develop and acetonuria may become 



SALOL 473 

marked. The use of chloroform for anesthesia, when such doses of 
salicylic acid are being used, is probably more dangerous than usual. 
(See Chloroform.) It is impossible to enumerate all the untoward 
effects which have been noted, but it is worthy of remark that very 
few deaths have taken place. 1 Binz thinks that full doses of salicylic 
acid may produce abortion in women who already have a tendency 
to abort, and Yineberg thinks that menorrhagia and metrorrhagia 
are caused by it. 

Contraindications to the use of the salicylates are meningeal inflam- 
mation or congestion, middle-ear disease, marked albuminuria, inac- 
tivity of the kidneys, particularly that occurring in pregnancy, and 
parenchymatous nephritis. 

Administration.— Salicylic acid has a nauseous taste and is irritant 
to the stomach. It may be given in a solution of glycerin and com- 
pound tincture of cardamom or its taste may be masked by the use of 
syrup of bitter orange peel or syrup of ginger. The following formula 
may be used: 

I^ — Acidi salicylici 5ij (8.0) 

Tincturse lavandulse compositse f 3vj (180.0) 

Glycerini fSij (60.0) 

S. — A tablespoonful (16.0) every four hours. 

Salicylic acid is best given in capsule with a little sodium bicarbon- 
ate, but as it is irritant to the stomach in so concentrated a form, the 
capsule must be taken with water or milk, and should follow rather 
than precede meals. (See Salicylate of Sodium.) 

If buzzing in the ears produced by this acid is annoying, bromide 
of sodium in the dose of 20 grains (1.3) will generally give relief. 

Salicylic acid ointment ( Unguentum Acidi Salicylici, B. P.) is a 
useful preparation for external application in chronic, deep-seated 
skin diseases. 

SALOL. 

Phenylis Salicylas, U. S., Salol, B. P., is a white crystalline powder, 
faintly aromatic and almost without taste. It is not soluble in water, 
but is in alcohol, and an alcoholic solution forms an imperfect emulsion 
when mixed with water. Salol is also slightly soluble in copaiba, in 
the oils of sandalwood and of turpentine, and in mineral oils. This 
solubility is very useful in prescribing it with these remedies in certain 
diseases of the genito-urinary organs. (See Gonorrhea.) 

Salol is a compound of 60 parts of salicylic acid and 40 of phenol, 
and is decomposed by the pancreatic juice into these two substances. 
For this reason overdoses are capable of producing symptoms of 
phenol poisoning. Thus 20 grains of salol (1.3) taken five times a 
day will cause a person to take 40 grains (2.6) of phenol, which is 
almost a poisonous dose. 

1 See author's Boylston Prize Essay of Harvard University on Antipyretics. 



474 DRUGS 

Hesselbach has proved that large doses of salol are very apt to 
affect the kidneys unfavorably, and rightly believes it to be contra- 
indicated in all cases of renal inflammation of an acute type. 

It is worthy of note that the drug rarely produces untoward effects, 
although at one time a number of observers accused it of frequently 
doing so. 

Salol is used for the same purposes as salicylic acid in the treat- 
ment of rheumatism when the stomach is so irritated that it cannot 
bear the latter drug, as salol is dissolved in the small intestine. A dose 
often used is 5 grains (0.3) an hour, but this is too much, as a rule, 
and may produce renal irritation. Salol is also useful in muscular 
rheumatism and neuralgia due to exposure. In pharyngitis 5 grains 
(0.3) of salol, given three times daily, is a valuable part of the treat- 
ment of the affection, and in persons subject to chronic sore-throat due 
to the lithemic diathesis this treatment will often produce excellent 
results. It is of the greatest use in duodenal catarrh and catarrhal 
jaundice to arrest intestinal fermentation. 

In the treatment of gonorrhea in all its stages salol may be employed 
by the mouth, as in the elimination of its ingredients it acts as an 
antiseptic and tends to sterilize the urethra at each act of micturition. 
(See Gonorrhea.) 

Salol is of great value in intestinal indigestion and fermentation, 
and is sometimes used in cases of mild or pernicious anemia when 
it is thought that the development of decomposition products is their 
cause. (See Anemia.) In diarrhea dependent upon such causes salol 
is one of the best remedies we have, since it renders the intestinal 
canal antiseptic, and so removes the cause of the disorder, instead of 
locking the putrid material in the bowel, as does opium. In cholera 
morbus the following is very useful: 

]$ — Phenylis salicylates 5J (4.0) 

Bismuth subnitratis . . „ 5ij (8.0) 

Mistime cretse q. s. ad fBiij (90.0). — M. 

S. — Two teaspoonfuls (8.0) every two hours. Shake well. 

Wide experience with the drug in the treatment of cholera during 
epidemics has proved it to be one of the best remedies that can be 
employed in the treatment of this disease. 

Salol may be given in wafers, capsules, or pills, in the dose of 5 
grains (0.3) or more. 

SALOPHEN. 

Salophen (Salophenum) has been introduced as a substitute for 
salol, and is said to possess the advantage of being far less poisonous 
than salol, because in this case the phenol of the salol is replaced by 
a compound of phenol, which is innocuous. Experiments on animals 
seem to indicate that these theoretical advantages are present in fact. 
Salophen is broken up in the intestine by the juices there present, 
and the result is salicylic acid and acetylparamidophenol. Salophen 



SANGUINARIA 475 

contains about 10 per cent, less salicylic acid than does salol (51 per 

cent.). 

Therapeutics.— For the therapeutics of salophen the reader is 
referred to the article on Salol, as the indications for both drugs are 
identical, save the salophen can probably be used when salol cannot be 
employed. The dose of salophen is from 5 to 20 grains (0.3-1 .3) three 
times a day. It can be very effectually combined with acetphenetidin 
in the treatment of neuralgia. In subacute rheumatic affections it is 
certainly very useful. 

SALVARSAN. 1 

(See Arsphen amine.) 

SANDALWOOD OIL. 

Sandalwood oil (Oleum Santali, U. S. and B. P.) is derived from 
the wood of Santalum album, a tree of India, and has a hot, burning 
taste. In overdose the oil is capable of producing great irritation of 
the genito-urinary passages. 

Therapeutics.— The oil of sandalwood is much used by genito- 
urinary surgeons in chronic gonorrhea and gleet, and in chronic cystitis. 

In the subacute stage of bronchitis, when the expectoration is thick 
and ropy, the oil is efficacious. In the excessive cough following influ- 
enza it is of great value. In all cases it should be given in capsule in 
the dose of 5 to 20 minims (0.3-1.3), 5 minims (0.3) being usually 
sufficient, although druggists generally keep it in 10-minim (0.6) 
capsules. 

SANGUINARIA. 

Sanguinaria, U. S., or blood-root, is the rhizome of Sanguinaria 
canadensis, and has been largely used in medicine, but is a dangerous 
remedy, possessing more power for harm than good. Its chief alkaloid 
is sanguinarine. 

Poisoning.— Sanguinarine in poisonous dose causes vomiting, purg- 
ing, profuse salivation, and finally tonic convulsions which are spinal 
in origin. Death is due to respiratory failure, but the circulation is 
much decreased in force and frequency. 

Therapeutics.— The employment of sanguinaria in chronic bronchitis 
is about the only purpose for which it is now employed to any extent. 
As an emetic in croup it has been largely used, but is too irritating and 
depressing, and should not be so employed. According to Bartholow, 
the drug acts as an hepatic stimulant, and is of service in g astro-intesti- 
nal catarrh and jaundice. 

Administration.— The dose of the fluidextract is 1 to 5 minims (0.06- 
0.3) as an expectorant, or 10 to 30 minims (0.6-2.0) as an emetic. 

1 By using the American name arsphenamine physicians will avoid employing 
a German-made product and so directly rewarding the holders of German patented 
articles. 



476 DRUGS 

If the drug does not cause vomiting after an emetic dose, it must not 
be allowed to remain in the stomach, as it is poisonous. The tincture 
(Tinctura Sanguinarice, U. S.) is the best preparation to use, and may 
be given in 20- to 30-minim (1.3-2.0) doses as an expectorant, and 
1 to 3 drams (4.0-12.0) as an emetic. The vinegar (Acetum Sangui- 
narice) is no longer official, but is given in the dose of 10 to 30 minims 
(0.6-2.0), and as an emetic in the dose of 2 to 4 drams (8.0-16.0). 

SANTONIN. 

Santoninum, U. S. and B. P., is a neutral principle derived from 
Levant worm-seed or Santonica, which is the unexpanded flower- 
heads of Artemisia pauciflora (Maritima, B. P.), a plant of Asia 
Minor and Turkestan. Santonin is soluble in alcohol and chloro- 
form, but slightly so in water. Santoninic acid is formed by warming 
santonin with alkalies, and Hesse has found that santonin is an 
anhydride of santoninic acid. Santoninic acid is more soluble than 
santonin. 

Poisoning.— Santonin causes, when taken in overdose, muscular 
tremors, convulsive movements, unconsciousness, and sometimes 
epileptiform convulsions. 

One of the most common symptoms of the poisoning is chroma- 
topsia or xanthopsia, during the existence of which all objects look 
yellow. This is due to the staining of the humors of the eye by the 
drug. This may go on to total blindness or pass away in a few days. 
If the vision is not yellow, it may be green. The urine is also stained 
—first yellow, then saffron, and finally purple red, or is bloody looking. 
This is not due to the presence of blood, but to the drug. Poisonous 
doses of the drug do not cause gastro-enteritis. 

Therapeutics.— Santonin is used for the removal of the roundworm, 
and is very efficacious. It has no influence on the tape-worm. It 
should be given in the manner of all vermifuges (see Worms)— namely, 
at a time when the alimentary canal is empty. Santonin is said to 
have a distinct influence over vision, increasing, in medicinal amount, 
its acuity whenever the optic nerve is at fault. In urinary incon- 
tinence santonin will often produce a cure after all other remedies fail. 

Santonin may be given in the dose of 1 to 2 grains (0.06-0.12) 
to an adult in capsule or wafer. The crystals should be used, not 
the powdered santonin. Immediately after the drug is used, a 2- or 
3-grain (0.12-0.2) dose of calomel is to be taken, and followed by a 
saline purge six hours later, as the flow of bile caused by the mercurial 
is particularly useful in making the worm let go its hold. 

Santoninate of sodium (Sodii Santoninas) is a useless, harmful 
preparation, never to be employed except for the benefit of the eye 
when vision fails through disease of the optic nerve. Introduced 
into medicine because of its solubility, it is absorbed into the system, 
which is just what is least desired in an anthelmintic, which should 



SAVINE 477 

seek the worm in the bowel, not by entering the blood. In eye affec- 
tions the dose may be from 2 to 8 grains (0.12-0.50) a day, according 
to the age of the adult. 

Untoward Effects.— In addition to the curious effects already named 
santonin may cause urinary incontinence even in medicinal dose. 

Administration.— Santonin is best given in the form of a troche or 
lozenge (Trochisci Santonini, B. P.) 1 grain (0.06) each, but it is to 
be distinctly borne in mind that the Trochisci Sodii Santoninatis 
of the U. S. P. of 1880 are not to be sold to the patient. A useful 
recipe is as follows : 

I£— Santonini .....' gr. v (0.3) 

Pulveris sacchari albee 5iij (12.0) 

Pulveris acacise •. . . . gr. viij (0.5) 

Misce bene, et adde 

Mucilaginis acacise gtt. xvj (1.0) 

Aquse q. s. 

Ft. in troches No. x. 

S. — One or two lozenges, as directed. 

SARSAPARILLA. 

Sarsaparilla, U. S., is the root of Smilax medica, Smilax ornata, 
and other species of Smilax, growing chiefly in Central America. 
The drug is devoid of any marked physiological action, yet seems 
to possess some power over the general condition of the system. 
Thus while sarsaparilla seems utterly without effect in the hands of 
most physicians when given alone, it often seems to do good and to 
increase the effects of other drugs when combined with them, so that 
some cases of syphilis which are of an obstinate character are said to 
yield to iodide of potassium and sarsaparilla when the iodide alone 
fails. Sarsaparilla is largely used in domestic medicine as a "blood- 
purifier," and is a prominent constituent of many patent medicines. 
It is useless for such purposes and is a much overrated remedy. 

Administration.— Sarsaparilla is most commonly given in the form 
of the compound syrup (Syrupus Sarsaparilla^ Compositus, U. S.), 
composed of sarsaparilla, sassafras, liquorice, gaultheria, anise, and 
senna, dose 1 to 4 fluidrams (4.0-16.0). (See Iodide of Potassium.) 
The other official preparations of the U. S. P. are the compound fluid- 
extract (Fluidextr actum Sarsaparillce Compositum) , similar to the 
syrup in composition, dose ^ to 1 fluidram (2.0-4.0); and the fluid- 
extract (Fluidextr actum Sarsaparilla;) , dose J to 1 fluidram (2.0-4.0). 
The B. P. preparation is a liquid extract (Extractum Sarsa? Liquidum), 
dose J to 4 fluidrams (2.0-16.0); and Liquor Sarsce Compositus Con- 
centratus, dose 2 to 8 drams (8.0-30.0). 

SAVINE. 

Sabina is the tops of Juniperus sabina, an evergreen shrub of 
Northern Europe, Asia, and America. It contains a volatile oil. 



478 DRUGS 

Locally applied, this oil is more of a counterirritant than is turpentine, 
and if swallowed in poisonous amount causes nausea, vomiting, gastro- 
enteritis, unconsciousness, suppression of urine and death. If the 
individual be a pregnant female, abortion takes place as death 
approaches, but very rarely before this time. Profuse flooding nearly 
always accompanies the abortion and the drug cannot be used to 
empty the uterus without great danger. 

Therapeutics.— The oil, taken in the dose of 5 to 10 minims (0.3- 
0.6), repeated every three or four hours, acts as a powerful stimulant 
to the uterus and ovaries, causing hyperemia and aiding in the pro- 
duction of menstruation in cases of amenorrhea. It may also be 
employed with advantage in some cases of Menorrhagia. The drug is 
best given in emulsion or capsule. The fluidextract is given in the 
dose of 5 to 15 minims (0.3-1.0). 

SCAMMONY. 

Scammoniae Radix, B. P., is a mixture of gum-resins from the root 
of Orizaba Jalapa, growing in Asia Minor and Syria. Its active 
principle is sometimes called jalapin. 

Therapeutics.— Scammony is an irritant, drastic, hydragogue purge, 
which causes a good deal of griping and exerts a cholagogue effect. 
If an inflammatory condition of the bowels is present, its use is contra- 
indicated. 

The ingestion of poisonous doses is to be followed by treatment 
suitable for gastro-enteritis. Scammony is given in the dose of 2 to 5 
grains (0.12-0.3), always in combination with some other similar 
drug— as, for example, colocynth. Scammony forms part of the 
compound extract of colocynth (Extractum Colocynthidis Compositum, 
U. S. and B. P.), the dose of which is 1 to 3 grains (0.06-0.19) as a 
laxative, 5 to 20 grains (0.3-1.3) as a purge; 2 to 8 grains (0.13-0.52) 
B. P. The resin (Resina Scammoniw, U. S.; Scammonice Resina, B. 
P.) is given in the dose of 3 to 8 grains (0.19-0.52). The B. P. 
preparations of scammony are Pilula Scammonii Composita, dose, 
5 grains (0.3), and Pulvis Scammonii Compositus, dose, 10 to 20 
grains (0.65-1.3). The last two preparations are composed of 
scammony, ginger, and jalap. 

SCARLET RED. 

Medicinal scarlet red occurs as a dark reddish-brown powder which 
is insoluble in water and but slightly so in cold alcohol, acetone, ether, 
and benzene. It is, however, soluble in chloroform and very soluble 
in fats and oils, and slightly soluble in petroleum and paraffin. For 
these reasons lard should be used as the ointment base, not petrolatum. 
Its chemical name is amido-azo-toluene-azo-beta-naphthol. 
Pk Therapeutics.— Scarlet red is used to stimulate the growth of epithe- 
lium over clean granulating surfaces. If the part affected is very 



SCOPARIUS AND SPARTEINE 479 

acutely inflamed, it must be used with caution. After it has been 
applied in ointment for twenty-four to forty-eight hours it should be 
followed by a soothing salve, as of pure lanolin. After the part is 
cleansed with warm water and soap, scarlet red can be applied to bed- 
sores, leg ulcers, slowly healing burns, and on clean venereal and 
syphilitic ulcers in ointment form of 2 to 8 per cent, strength. If the 
ulcer is very large the ointment should be applied only around the 
edges. It is not antiseptic in its action. The 10 per cent, ointment 
commonly found in the market, diluted one-half with liquid albolene, 
is a useful application in ozena after the crusts are removed with 
peroxide of hydrogen. It has also been used to aid in the healing of 
perforation of the tympanic membrane. In the latter cases the treat- 
ment must be stopped every few days to avoid excessive stimulation 
and irritation. 

SCOPARIUS AND SPARTEINE. 

Scoparius (Scopari Cacumina, B. P.), or broom, is the tops of 
Cystisus scoparius. It contains scoparin and sparteine, the first 
being a crystalline principle and the second a liquid alkaloid. The 
second (sparteine) is the alkaloid used in medicine in the form of 
a sulphate (Sparteine Sulphas, U. S.), which is a crystalline salt 
readily soluble in water. 

Physiological Action.— As scoparius depends for its medicinal value 
almost entirely upon sparteine, what is here said applies to both the 
crude drug and the alkaloid. 

Nervous System.— Sparteine acts on the nervous system very 
decidedly if given in toxic doses, depressing the brain and spinal cord, 
chiefly in the motor tracts of the latter, thereby causing a decrease of 
reflex action and motor power, ending in complete paralysis. These 
changes occur both in man and in the lower animals. 

Circulation.— Upon the circulation sparteine acts as a stimulant. 
It quickens the pulse-rate in moderate doses, and also raises arterial 
pressure. The force of the contraction of the ventricles is also 
increased. In large poisonous doses the drug acts as a circulatory 
depressant. 

Respiration.— Upon this function sparteine, in small amounts, has 
no effect, but poisonous doses kill by paralysis of the respiratory 
center. 

Kidneys.— There is little evidence to prove that sparteine acts 
directly on the kidneys. MacNider believes from his investigations 
that when diuresis is produced by its use the increased flow is due to a 
rise in blood-pressure. 

Poisoning.— The symptoms of poisoning consist in trembling and 
incoordination of movement, and clonic and tonic convulsions, fol- 
lowed by a second stage of depression of the nervous system and 
general enfeeblement. 



480 DRUGS 

Therapeutics.— Sparteine sulphate has been recommended in all 
states of the heart in which digitalis is of service, and it is sometimes 
useful in those fairly frequent cases where digitalis fails. In cardiac 
arrhythmia or palpitation it is thought to be of great service by those 
who have used it most. Clark found it of value in Graves s disease and 
in nearly every circulatory abnormality, but in the judgment of the 
author sparteine is not a very useful drug— one only to be turned to as 
a last resource after more generally used remedies fail; or, in other 
words, it is not a remedy to be employed as a "stand-by" in the 
manner in which digitalis is used. 

In the few cases in which it has been used by the writer it failed to 
be of service, perhaps because the cases were desperate and the drug 
was tried after all the other remedies had failed. The dose is as 
variable as its action. Some state it to be 2V grain (0.003), while still 
others recommend 2 to 4 grains (0.12-0.25). The latter dose is more 
nearly the correct one. To get the best effects it should be given every 
two hours in the dose of J grain. The drug should be given in watery 
solution or in pill. 

One or 2 grains (0.06-0.12)' given hypodermically are useful for 
suppression of urine after operations. 

Potts claims to have found sparteine of value in the treatment of 
tremor, as in paralysis agitans, in the dose of J to \ grain (0.015- 
0.03) three times a day. 

Scoparius itself is used in decoction, made by adding \ ounce (16.0) 
of the broom-tops to a pint (480) of water, and boiling them down to 
a \ pint (240). Of this an ounce should be taken every three hours. 
This decoction is one of the most efficient diuretics in cardiac dropsy. 
The official preparations of the B. P. are an infusion (Infusum 
Scoparii), and the juice (Succus Scoparii), dose 1 to 2 drams (4.0-8.0). 

SCOPOLAMINE. 

Scopolamine, or hyoscine, is an alkaloid derived from the dried 
rhizome of Scopola Carniolica, sl plant of southern Europe, yielding 
not less than 0.5 per cent, of mydriatic alkaloids, which possess 
medicinal powers closely resembling those of belladonna and its sister 
drugs. Its physiological action is particularly closely allied to that of 
the alkaloids of hyoscyamus. As stated in the article on Hyoscine, 
it has been introduced in its stead. The terms hyoscine and scopol- 
amine are used interchangeably. (See Hyoscine.) 

Hyoscine itself is rarely employed, the hydrobromide {Scopolamine 
Hydrobromidum, U. S.) being preferable. It also occurs as the 
hydriodide and hydrochloride. 

Scopolamine administered hypodermically with morphine has been 
largely used by some surgeons for the production of general anesthesia, 
the condition being produced by the administration of these drugs at 



SEIDLITZ POWDER 481 

intervals of from one to three hours for two to four doses preceding the 
time of operation. In most cases one or two doses only are employed 
to cause primary stupor, which is then maintained by the adminis- 
tration of ether or chloroform. The dose of scopolamine used for 
anesthesia has usually been T ^ grain (0.0006), combined with yV 
grain (0.005) of morphine sulphate, at each injection. The so-called 
u scopolamine-morphine method," when used to supplant ether and 
chloroform, has not proved popular, and experience seems to indicate 
that it is by no means devoid of danger, but used beforehand it allays 
fear, lessens the amount of anesthetic needed, decreases post-anes- 
thetic vomiting, and causes the patient to sleep for several hours after 
the operation. (See also Hyoscine and Morphine.) 

Scopolamine and morphine have also been used together to relieve the 
pains of labor "Twilight Sleep." Scopolamine, yj-^ grain (0.00043), 
and J grain (0.01) of morphine sulphate are injected hypodermically 
when the pains are occurring about every four or five minutes and last- 
ing for thirty seconds. Great care must be exercised in determining 
that the labor has actually begun. Such a dose usually acts in about 
half an hour, causing sleep between the pains. If this is not sufficient 
to markedly relieve pain, the dose of scopolamine, without the mor- 
phine, is repeated. The patient should be protected from noise and 
bustle after the dose is given. If memory is preserved after this second 
dose, the same dose of scopolamine is again given. This treatment 
is said to cause a painless labor devoid of accident to mother, and 
although the groaning of the woman may indicate pain, she usually 
states afterward that she has not suffered. It is probably not as safe 
for the child, and all are agreed that the patient must be so care- 
fully watched that it should be used with care and only in a lying-in 
institution. 

SEIDLITZ POWDER. 

Under the official name of Pubis Effervescens Compositus the U. S. 
P. recognizes a purgative powder (Palvis Sodoe Tartaratce Effervescens, 
B. P.) made by taking the bitartrate of sodium and potassium, or 
Rochelle salt 120 grains, and bicarbonate of sodium 40 grains, which 
are wrapped in blue paper, and 35 grains of tartaric acid placed in a 
white paper. The contents of each paper are dissolved in water— 
half a tumblerful— and the two solutions added to one another and 
swallowed during effervescence. As much as two powders may be 
used, but this is generally too large an amount unless full purgation 
is needed. In sick stomach associated with constipation, when a whole 
powder cannot be retained, the two powders should be divided into 
fourths, and a fourth added to a fourth dissolved in a half-wineglassful 
of water and taken every fifteen minutes until the entire powder is 
ingested. This will often settle the stomach and produce purgation. 
31 



482 DRUGS 



SENEGA. 



Senega, U. S. [Senega Radix, B. P.) is the root of Polygala senega, 
a small plant of the United States, containing a principle known as 
polygalic acid and senegin. 

Therapeutics.— Senega is used in medicine as a stimulating expec- 
torant in the subacute and chronic forms of bronchitis. It has also 
been employed as a diuretic in cardiac dropsy or that due to renal 
disease. In cardiac disease it should not be used, and indeed it is 
rarely employed at present except in combination with other drugs in 
expectorant mixtures. 

Administration.— Senega is used in the form of the fluidextract 
(Fluidextractum Senega) U. S.), dose 10 to 20 minims (0.6-1.3) and 
the syrup (Syrupus Senegce, U. S.), dose 1 to 2 drams (4.0-8.0). It 
is also used in Coxe's Hive Syrup. The official preparations of the 
B. P. are— a tincture (Tinctura Senega), dose 1 to 2 drams (4.0-8.0), 
and an infusion (Infusum Senegce), dose 1 to 2 ounces (30.0-60.0). 

SENNA. 

Senna, U. S., is the most drastic of the laxative purges used for the 
relief of constipatio?i. It is the leaflets of Cassia acutifolia and Cassia 
angustifolia, and contains a very acrid irritant purgative principle 
known as cathartic acid. Senna is official in the B. P. as Senna 
Indica and Alexandrina. 

Physiological Action.— Senna acts as a purge, producing copious 
stools, often with much griping if it is used alone. According to 
Rutherford and Vignal, it materially increases the flow of bile, but 
it is seldom, if ever, used in medicine as a cholagogue, although, 
according to Prevost and Binet, cathartic acid has an influence over 
biliary secretion. Hess has found that the drug acts directly as a 
stimulant upon the mucous membrane, and so produces a local 
peristalsis as it is moved along. It is also known that the drug is 
eliminated in the milk, and for this reason care should be taken in 
giving the drug to nursing mothers, as it will purge the nursling. 

Administration.— Senna is generally combined with other drugs for 
the relief of constipation, but may be used alone. If this is done, 
the fluidextract (Fluidextractum Senna, U. S.) may be employed in 
the dose of 1 to 2 drams (4.0-8.0) to a child or 4 drams (16.0) to an 
adult. It is, however, always better to give children the more 
agreeable confection (Confectio Sennce, U. S. and B. P.) in the dose of 
\ dram (2.0) to a child, or 1 to 2 drams (4.0-8.0) to an adult. As the 
confection is apt to cause gastric disorder if used continuously because 
of the sugar contained in it, its use is limited to a small class of cases. 

In the treatment of the constipation of pregnancy senna is thought 
to be very useful. In these cases and in other where cascara sagrada 
alone will not move the bowels, senna may be prescribed as follows: 

1$ — Fluidextracti sennae f5ij (60.0) 

Fluidextracti cascarse sagradse f5j (30.0). — M. 

S. — Teaspoonful (4.0) at night, or night and morning. 



SILICATE OF POTASSIUM OR SODIUM 483 

Should this produce griping 1 to 5 minims (0.05-0.25) of nuidextract 
of belladonna may be added to each dose. Under the name of Black 
Draught a mixture of senna, manna, fennel, and sulphate of mag- 
nesium has been largely used (Infusum Sennas Composition, U. S.) in 
the dose of 4 ounces (120.0). It is an active hydragogue purge. The 
syrup (Syrupus Sennas, U. S. and B. P.) is given in the dose of 1 to 4 
drams (4.0-16.0). 

One of the best ways to use senna is in the compound liquorice 
powder (Pubis Glycyrrhizce Compositus, U. S. and B. P.), which is a 
good laxative in the dose of 20 to 30 grains (1.3-2.0), 1 to 2 drams 
(4.0-8.0), B. P. Compound liquorice powder is composed of senna, 
liquorice, oil of fennel, washed sulphur, and sugar. 

Infusum Sennas, B. P., is given in the dose of 1 to 2 ounces (30.0- 
60.0); Mistura Sennas Composita, B. P., in the dose of 1 to 2 ounces 
(30.0-60.0); and Tinctara Sennas Composita, B. P., in the dose of 
1 to 4 grams (4.0-16.0). Liquor Sennas Concentratus, B.P., is given 
in the dose of 1 dram (4.0) . 

Senna, because of its chrysophan, may stain the urine carmine if 
that fluid is alkaline, or yellow if it is acid. Xo alarm should be felt 
if either color appears in this secretion. Often it is necessary to warn 
the parents of a child of the possibility of such an occurrence, in order 
to prevent alarm on the part of the mother, who otherwise may 
think that hematuria was present. 

SERPENTARIA. 

Serpentaria, U. S. (Serpentarias Rhizoma, B. P.), or Virginia snake- 
root, is the rhizome and rootlets of Aristolochia serpentaria and Aristo- 
lochia reticulata, plants of the Southern United States. It contains an 
active principle, aristolochin, which is never used in medicine. 

Therapeutics.— Owing to the rather pleasant, warm taste of ser- 
pentaria, and the fact that it stimulates secretion, it is used largely as 
a vehicle for other more potent remedies. It has tonic properties, 
and in consequence has been largely used in the treatment of atonic 
dyspepsia and indigestion. It is said to be a sexual stimulant, but 
this is doubtful, to say the least. In overdose it is an irritant, and 
will cause vomiting and purging if large amounts are taken. 

Administration.— Serpentaria is given in the form of the fluidextract 
in the dose of 10 to 40 minims (0.6-2.6) . It also enters into Huxham's 
Tincture of Cinchona ( Tinctura Cinchonas Composita, U. S. and B. P.). 
Infusum Serpentarias, B. P., is given in the dose of \ to 1 ounce (15.0- 
30.0). 

SILICATE OF POTASSIUM OR SODIUM. 

Soluble glass, or silicate of potassium or sodium, occurs as a clear, 
syrupy fluid. It is used as a splint in the dressing of fractures and 
sprains, as it rapidly becomes hard and immovable when painted over 



484 DRUGS 

the bandages. Silicate of potassium or sodium may be universally 
substituted for plaster-of -Paris. The solution of silicate of sodium is 
no longer official. 

SILVER ARSPHENAMINE. 

Silver arsphenamine, as its name implies, is a compound of silver 
with arsphenamine. In appearance it is grayish-black powder put 
up in an ampoule. When made into a solution it is neutral in reaction 
and appears dark-brown in color, but if it is oxidized the powder does 
not readily dissolve and the fluid is opalescent. When oxidized it is 
toxic and must not be used. Its arsenic content is less than that of 
arsphenamine; 22.4 per cent, arsenic and 14.1 per cent, silver, whereas 
in the older drug the arsenic content is 30 per cent, and in neoars- 
phenamine 20 per cent. 

The exact manner in which this combination acts is uncertain, some 
supposing that it attacks the parasite directly while others claim 
that it seems to anchor the arsenic compound more effectively to the 
parasite. For these reasons silver arsphenamine has been advanced 
as superior to the older products and it has been claimed that the 
effective dose is less by nearly one-half. The dose usually employed 
is 0.1 to 0.3 gram repeated every day to every four days and the treat- 
ment is usually persisted in until from eight to sixteen injections are 
given. Some give much larger and some smaller doses than this. 
Not more than 2 grams should be used in a month not only because 
of the arsenic effect, but also because argyria may be induced. It 
would seem that silver arsphenamine has no greater therapeutic 
power than arsphenamine and that if mercury is to be actively 
employed the silver preparation had better be supplanted by the 
older preparation since its use requires the system to deal with the 
elimination of three metals instead of two. The quantity of distilled 
water employed in making the solution varies with the wish of the 
physician, the ordinary amount being 10 cc for each 0.1 gram used. 
Sometimes normal salt solution is employed. Silver arsphenamine 
should be injected very slowly and great care taken that it does not 
enter the perivenous tissues. 

SILVOL. 

Silvol appears in the form of black lustrous granules, slightly 
hygroscopic and hence very readily soluble in water. Solutions can 
be very quickly made, even having a concentration as high as 50 per 
cent, by weight. Ordinary solutions containing 2 per cent, or more 
of silvol are a brownish-black color, but when quite dilute this solu- 
tion has a characteristic brownish-yellow tint. The substance is 
readily soluble in water and insoluble in acetone, alcohol, ether, 
chloroform, oils and fats. 

Pharmacological tests upon animals would seem to indicate that 
silvol can be defined as practically " non-toxic. " 



SOAP 485 

Silvol is now available in the form of one-ounce vials of the 
granular powder; also in capsules, each of which contains 6 grains. 
These latter are specially prepared for the making of solutions, it 
being only necessary to empty the contents of one, two or more cap- 
sules in a measured quantity of water to produce a solution of such 
concentration as the physician may require. It also appears as 
silvol ointment containing 5 per cent, of the medicament. 

In 20 per cent, solution it is an excellent application in the nose in 
the early stages of acute coryza and also in acute pharyngitis. 

Injections of 10 to 20 per cent, solution, three or four times per day 
may be used in gonorrhea. A twenty-five per cent, solution is used 
in ophthalmia neonatorum and in purulent ophthalmia. 

SOAP. 

Sapo, U. S. (Sapo Durus, B. P.), is prepared from sodium hydroxide 
and olive oil, although other alkalies and oils may be employed in 
the manufacture of the soaps which are used medicinally. Castile 
soap, if good, is the best representative of a pure soap. 

Soap may be cut into the form of a suppository and used to pro- 
voke movements of the bowel in young children who are suffering 
from constipation, by placing it just inside the anus, having previously 
dipped it into water an instant to make it slippery. It may also be 
used as an enema, dissolved in warm water, or a mixture known in 
Philadelphia as the "House Mixture" may be employed in the case of 
an adult. This consists of a mixture of water, soft soap, and molasses 
in varying proportions, and if flatulence is present turpentine and olive 
oil are added to it. The preparation is as efficient as it is cheap and 
dirty. Soap is also used as an antidote to many poisons and as an aid 
to emetics. 

Soft soap (Sapo Mollis, U. S. and B. P.), often called green soap, is 
usually brown. It is a soft soap made by the use of potash and 
linseed oil, and is largely used by dermatologists in the treatment of 
eczema and similar skin diseases where a detergent, stimulating 
application is needed. It is sometimes called " German soft soap," to 
distinguish it from the ordinary soft soap of the United States, which 
is an impure substance often made of rancid fats, containing a large 
excess of alkali, and never used except for scouring purposes. Green 
soap is employed not only as green soap, but also in the liniment 
(Linimentum Saponis Mollis, U. S.), which is to be thoroughly rubbed 
into the part when used medicinally, well washed off, and afterward 
simple cerate or some other soothing salve applied. 

Soap liniment (Linimentum Saponis, U. S. and B. P.), or opo- 
deldoc, as it is called in domestic medicine, is largely used for rubbing 
stiff muscles and sprains. It is generally employed to carry more 
active external remedies, such as opium or aconite. 

1$ — Tincturse aconiti, 

Tincturse belladonna?, 

. Tincturse opii aa f 3ij (8.0) 

Linimenti saponis q. s. ad f3vj (180.0). — M. 



486 DRUGS 

Soap plaster (Emplastrum Saponis, U. S. and B. P.) is used as a 
thick, heavy protective for bed-sores or where the formation of bed- 
sores is feared. It is also used as a support about sprained joints. 

SODIO- SALICYLATE OF THEOBROMINE. 

Theobromince Sodiosalicylas, U. S., known as diuretin {Theo- 
bromines et Sodii Salicylas, B. P.), derives its name from the extra- 
ordinary power which it is said to possess of producing a great increase 
in the urinary flow from the kidneys. This power depends entirely 
upon the theobromine, which is a crystallizable, volatile, bitter alka- 
loid, closely allied to caffeine and xanthine, and derived from the seeds 
of Theobroma cacao, or the source of ordinary chocolate. Owing to the 
insolubility of theobromine, it has been found necessary to combine it 
with sodium salicylate, as under these conditions it is readily absorbed. 
The diuretic properties of this alkaloid were first discovered during 
a series of experiments made by Schroder, in Strasburg, in 1889, who 
found that the diuresis produced in man and the lower animals was 
marked. Many clinical trials in Europe and America have confirmed 
his observations, but there are a number of cases in which it signally 
fails, particularly in chronic Bright's disease. 

Theobromine does not have so stimulating an effect on the heart as 
does its relative caffeine, so that the circulatory effect, while showing 
a stimulant rather than a depressing tendency, is very slight. It 
slightly increases muscular power, but its peculiar affinity for the renal 
structure surpasses all its other activities. 

As the action of the drug depends upon its ability to stimulate the 
secreting epithelium of the kidney, the physician should remember 
that in cases of advanced renal disease, where the secreting structures 
are almost entirely destroyed, no result can be expected from its 
administration; but it is probable that the drug is useful in almost 
all conditions of dropsy, whether due to renal inactivity or cardiac 
disease, and is harmless to the patient even if the diuretic effect, does 
not ensue. The only contraindication, to the use of theobromine or 
diuretin is the presence of acute nephritis, when, of course, sedatives 
rather than stimulants are needed. So far as the writer is aware, no 
study as to the proportion of solids and liquids in the urine of patients 
under the influence of this drug have been made, but the fact that it 
stimulates the epithelium or secreting structures of the kidney would 
indicate that the solids are increased. 

As diuretin contains only from 30 to 50 per cent, of theobromine, 
it has to be given in very large amounts, as much as 1 to 2 drams 
(4.0-8.0) in twenty-four hours, preferably in divided doses of from 
10 to 20 grains (0.60-1.3) in capsule or in warm water. The former 
method is the better, as the taste of the drug is disagreeable and soapy. 
Diuretin must not be exposed to the air, as it undergoes decomposition. 
In many cases in which the writer has tried sodio-salicylate of theo- 
bromine he has failed to see any effect produced, and, while he has 
little confidence in the drug, he mentions it because others claim to 
have obtained good results from its use. 



SODIUM 487 



SODIUM. 



Sodium is a metallic element, the salts of which are usually white 
and colorless. It is not used in medicine, but many of its salts are 
employed. While potassium acts as a depressant to the body, sodium 
seems to exert comparatively little effect upon the animal economy. 
The salts vary in their power with the acid forming them. (See 
Benzoate of Sodium, Salicylate of Sodium, etc.) 

Acetate of sodium (Sodii Acetas, U. S.) is rarely if ever used in 
medicine as a substitute for acetate of potassium. The dose is 20 to 
40 grains (1.3-2.6) three times a day. 

Sodium Acid Phosphate. 

Sodii Phosphas Acidus, B. P., or Sodium Acid Phosphate (NaH 2 P0 4 - 
H 2 0), or monosodium phosphate, differs from ordinary sodium phos- 
phate, which is disodium or neutral sodium phosphate (Na 2 HP0 4 ,H2- 
O). When taken into the stomach it is not changed, but in the 
intestine it is converted into disodium phosphate and acts in a similar 
manner as a mild purge. The neutralization of the acid takes alkali 
from the blood, and as the system guards the normal alkalinity of the 
blood with the greatest care there is a prompt excretion of acid in the 
urine to maintain the normal balance. This makes an acid urine, 
which is desirable when it is alkaline and loaded with phosphates. It 
is also desirable when the colon bacillus infects the urinary tract, and 
it is desired to get the effect of hexamethylenamine which gives off 
its formaldehyde only in an acid urine. It is wise, therefore, to 
precede each dose of hexamethylenamine by some hours by a dose of 
15 to 20 grains (1.0-1.3) of acid sodium phosphate. It may be given 
dissolved in sweetened water so as to taste like lemonade. 

Sodium Bicarbonate. 

Bicarbonate of sodium (Sodii Bicarbonas, U. S. and B. P.) is largely 
used as an antacid in gastric fermentation and in sick headaches arising 
from this condition. Combined with calomel in powder, it certainly 
adds to its efficiency in increasing biliary flow, as all alkalies of this 
class liquefy and thin the bile. The drug has been widely employed 
in the treatment of rheumatism, and is found to be of great service 
in allaying pain and soreness in the joints when used in a lotion made 
by dissolving it in water and applying it to the part on lint or rags. 

In acidity of the stomach the following effervescing powder is useful: 
Bicarbonate of sodium (Sodii Bicarbonas), 30 grains (2.0) in one 
paper, and in the other 5 grains (0.3) of tartaric acid (Acidum Tar- 
taricum) . These are each dissolved in half a tumbler of water, added 
to one another, and swallowed during effervescence. 

Sodium Cacodylate. 

Sodii Cflcodylas, U. S., is a white, amorphous powder which readily 
dissolves in water. It uses in medicine are practically identical with 



488 DRUGS 

those of arsenic. (See Arsenic and Arsphenamine.) It is less 
poisonous only because the compound is so stable that arsenic is 
slowly set free. The drug is best administered hypodermically. The 
dose is 1 to 2 grains (0.06-0.12) subcutaneously, and 2 to 4 grains 
(0.12-0.25) by the mouth. In these doses given, as a rule, every 
other day it is a very efficient remedy in primary and secondary 
anemia. Its use by the stomach causes not only a strong, garlicky 
odor on the breath, but also gastric irritation, because it is decomposed 
in this viscus. 

Murphy advised the intramuscular injection every third or fourth 
day of 1 to 4 grains (0.05-0.2) in syphilis, and stated that it destroys 
the spirochete of this disease, but this is doubtful. The large and 
small doses are now ready for use in solution in ampoules, and these 
should always be used. 

Sodium Chloride. 

Chloride of sodium (Sodii Chloridum, U. S. and B. P.), or common 
salt, is a useful drug and food, aiding in maintaining the alkalinity 
of the blood and tissues and in the formation of gastric juice, being 
changed by the lactic acid of the stomach into lactate of sodium, 
thereby setting free hydrochloric acid, which acts not only by aiding 
digestion, but in the production of pepsin from pepsinogen of the 
gastric tubules. The dose is 10 to 20 grains (0.6-1.3). 

It is official under the name Liquor Sodii Physiologicus, U. S., or 
noimal salt solution. 

Sodium Citrate. 

Sodium citrate (Sodii Citras, U. S.) may be used as a substitute for 
citrate of potassium but is less active. It has been highly recom- 
mended to aid in the digestion of milk by bottle-fed babies in that it 
prevents the formation of tough curds. When it is used it is not 
necessary to largely dilute cows' milk with water for these patients. 
The dose should be about 1 to 2 grains (0.05-0.1) to the ounce (30.0) 
of milk. The same drug may be used with advantage in cases of 
difficult milk digestion in adults suffering from gastric ulcer, gastritis, 
and typhoid fever. (See Buttermilk in Part III, Foods for the Sick.) 
It is also used to prevent coagulation of blood in the practice of indirect 
blood transfusion. A 2 per cent, solution is prepared and used in such 
a proportion that the amount of sodium citrate in the injected blood 
does not exceed 0.2 per cent. (See Transfusion, Part III.) 

Sodium Ethylate. 

Sodium ethylate is a whitish powder decomposed in the presence 
of water into alcohol and caustic soda, but soluble in absolute alcohol 
without decomposition. 

Sodium ethylate is employed in medicine as a depilatory— that is, 
for the purpose of removing hairy growths. To accomplish this pur- 



SODIUM 489 

pose it is necessary that the growth be dipped close to the skin, and 
that the drug be dissolved in absolute alcohol and applied over the 
roots of the hair with a glass rod. Soon after this application a crust 
forms, which should not be detached for two or three weeks, but which, 
in its removal at the end of this time, generally shows that all the roots 
of the hair have been destroyed. If not, the operation may be 
repeated as soon as the skin is in a condition to bear it. To prevent 
pain, a 5 per cent, solution of cocaine may be used hypodermically 
at the spot to be cauterized. It is worthy of remembrance that moles 
and small birthmarks, or nevi, may be removed by a similar applica- 
tion. Small scars may result. 

A solution, Liquor- Sodii Ethylatis, is official in the B. P. 

Sodium Hydroxide. 

Sodium hydroxide (Sodii Hydroxidum, U. S., Soda Caustica, B. P.) 
is milder than caustic potash, and its action is more readily controlled. 
It should be used in the same way and for the same purpose as is caus- 
tic potash, and the surrounding skin should be protected by adhesive 
plaster and oil or ointment. 

The soda must be kept in well-stoppered bottles made of hard, 
strong glass. The only official preparation in the U. S. P. is the 5 per 
cent, solution of sodium hydroxide, Liquor Sodii Hydroxidi. 

Sodium Iodide. 

Sodii lodidum, U. S. and B. P., is actually superior to potassium 
iodide in that it is less irritating to the stomach and less depressant 
to the heart. It is also far better in nephritis, since in this condition 
the potash salts are often retained and act as depressants. In other 
respects the effects are identicals (See Iodide of Potassium.) 

Howard strongly commends the intravenous use of sodium iodide 
in the strength of 8 per cent, in sterile distilled water and gives doses 
varying from 10 to 30 grains in this manner by syringe or arsphena- 
mine apparatus. The solution can be sterilized by boiling. 

Sodium Phosphate. 

Sodii Phosphas, U. S. and B. P., is a preparation which has been 
used with the idea that it can supplant phosphorus. This is, of course, 
an error, as it has an entirely different effect. It is particularly useful 
for bottle-fed children, who continually alternate between diarrhea 
and constipation, and is also useful in cases of rickets to regulate the 
bowels. It should be added to each bottle of milk in the dose of 2 to 
4 grains (0.12-0.25). Phosphate of sodium in small doses is slightly 
laxative, and large doses are purgative. Bartholow believed phos- 
phate of sodium to be the best remedy in hepatic cirrhosis said jaundice. 
To adults it should be given in the dose of 20 grains to 2 drams 
(1.3-8.0) once, twice, or thrice a day according to the laxative effect 
desired. It is best given dissolved in a teacupful of hot water. 



490 DRUGS 

Many cases of general wretchedness or headache due to auto- 
intoxication are relieved by the phosphate of sodium. 

The U. S. P. and B. P. also recognizes a preparation called Sodii 
Phosphas Effervescens; dose 2 to 4 drams (8.0-16.0). Sodii Phos- 
phas Exsiccatus (U. S.) is about twice the strength of the ordinary 
phosphate; dose J to 1 dram (2.0-4.0). 

(For an explanation of the purgative action of most salines see 
article on Magnesium Sulphate.) 

Sodium Sulphate. 

Sodii Sulphas, U. S. and B. P., or Glauber's Salt, is one of the irri- 
tant saline purges, rarely used in medicine by itself for human beings, 
but largely employed by veterinarians. The purgative dose for man 
is J to 1 ounce (16.0-30.0). If any intestinal inflammation is present, 
it is contraindicated. It produces large watery stools, with a good 
deal of griping. Sulphate of sodium is a prominent constituent of 
Carlsbad water, Hunyadi Janos, Hunyadi Arpad, and similar waters. 
(For an explanation of the action of salines in producing purgation, 
see Magnesium Sulphate.) 

Reverdin has recently claimed that small doses of 2 grains (0.12) of 
sulphate of sodium every hour are of great value in controlling capil- 
lary hemorrhages and for graver hemorrhages. It must be given by 
the mouth or intravenously. If given hypodermically he asserts it is 
useless. 

Under the name Sodii Sulphas Effervescens the B. P. recognizes an 
effervescent preparation of sodium sulphate, given in the dose of 2 
to 4 drams (8.0-16.0). 

Sodium Sulphocarbolate. 

(See Phenolsulphonates.) 

Sodium Thiosulphate. 

Thiosulphate of sodium (Sodii Thiosulphas, U. S.) or hyposulphite 
of sodium, occurs in large, transparent, colorless plates which effloresce 
when exposed to the air. It has a slight alkaline reaction, and is 
soluble in about equal parts of water, but insoluble in alcohol. 

Therapeutics.— Thiosulphate of sodium is used in the proportion 
of 1 dram (4.0) to the ounce (30.0) of water or lard in the treatment 
of parasitic skin diseases, particularly those due to the trichophyton 
fungus, such as pityriasis versicolor. It is also efficacious, locally 
applied, in rhus poisoning in the following prescription: 

1$ — Acidi borici, 

Sodii thiosulphatis, 

Resorcini aa gr. 15-30 (10-20) 

Aqua* fSviij (250) 

S. — -Apply on compresses. 

It may also be used for pruritus in the strength of \ dram (2.0) to the 
ounce (30.0) of water. In malarial hematuria sodium thiosulphate is 



SQUILL 491 

often given with advantage in the dose of from 10 to 30 grains (0.60- 
2.0) every four hours. How it acts in this condition is not known. 

Thiosulphate of sodium is largely used as a food preservative and 
in the amounts usually employed is harmless. 

SOLANUM CAROLINENSE. 

Solanum carolinense, or horse nettle, is a low perennial plant of 
the natural order Solanacece, a native of the Southeastern United 
States. 

According to studies made by Thornton, the drug depresses the 
cerebrum, but excites the spinal cord. It has been introduced into 
medicine for the purpose of relieving epilepsy, particularly when the 
disease occurs in childhood. In a limited employment of the drug 
the author has found it serviceable in diminishing the frequency and 
severity of the attacks. The beginning dose of the fluidextract is 15 
to 60 minims (1.0-4.0) three times a day, but it may be increased to 
as much as 2 drams (8.0) at a dose with advantage. 

SPIGELIA. 

Spigelia, U. S., pinkroot, is the root and rhizome of Spigelia mari- 
landica, or Carolina pink, a plant of the Southern United States. 

Poisoning.— The symptoms of poisoning by spigelia closely resemble 
those of belladonna poisoning. 

Therapeutics. — Spigelia is one of the most efficient remedies in the 
removal of round-worms, and is not dangerous when given with 
care. When employed for the removal of worms, the usual precau- 
tion should be taken in regard to the ingestion of food (see article on 
Worms), and the drug should be followed by a purge to sweep out 
the worm while it is narcotized. The purge should be one which is 
rapid in its action, such as the sulphate of magnesium. 

Administration.— The dose of spigelia in the form of the fluidextract 
(Fluidextractum Spigelice, U. S.) is 2 drams (8.0) ; that of the unofficial 
fluidextract of spigelia and senna (Fluidextractum Spigelice et Sennce) 
is | to 1 dram (2.0-4.0) for a child of two years of age; \ ounce (16.0) 
is the dose for an adult. The addition of fluidextract of senna makes 
the drug more efficient, and the mixture is generally not disliked by 
children. It is to be remembered that this latter mixture is no 
longer official. 

SQUILL. 

Scilla, U. S. and B. P., is the sliced bulb of Urginea maritima 
(Scilla, B. P.), a plant of the countries bordering on the Mediter- 
ranean. It contains scillin, scillipicrin, and scillitoxin, all of which 
possess poisonous properties, and none of which is used in medicine 
alone, except by few practitioners. 

Poisoning.— In poisonous doses squill produces vomiting, purging, 
dulness, stupor, intermittent palsy, convulsions, and death in ten to 



492 DRUGS 

twenty hours. These symptoms are preceded by a marked fall in 
temperature. The urine is suppressed or bloody and acute nephritis 
is produced. Gastro-enteritis may be marked. 

Physiological Action.— Squill possesses a physiological effect upon 
the heart closely allied to that of digitalis, and is thought by some to 
be capable of stimulating the heart muscle more powerfully than 
digitalis. Like digitalis, it is capable in overdose of inducing cardiac 
arrhythmia and even heart block. (See Digitalis.) 

It increases diuresis not only by raising blood-pressure in the kidney, 
as does digitalis, but by stimulating the secreting epithelium as well. 
In overdose it is a renal irritant. 

Therapeutics.— Squill is largely used as a stimulant or irritant 
diuretic, to affect the renal epithelium directly and promote secretion, 
and to tone up and excite to normal effort a kidney depressed by 
disease, as in chronic Bright'' s disease or renal congestion from cardiac 
trouble. In cardiac dropsy, when combined with digitalis, squill is a 
standard and much-used remedy, and is undoubtedly of value in aid- 
ing in the absorption of effusions in the pericardium, pleura, and 
abdomen. (See Digitalis.) Squill is usually given in dropsy, in pill 
form, as follows : 

I^ — Pulveris scillae gr. x (0.6) 

Pulveris digitalis foliorum gr. xx (1.3). — M. 

Fiant pilulse No. x. 

S. — One t. i. d. after meals. 

The employment of squill in bronchitis, although largely resorted 
to, is not to be commended, since its irritant action on the kidneys 
and stomach may cause trouble. The period for its administration is 
in the beginning of the second stage, when secretion is scanty or so 
excessive as to need proper stimulation of the mucous membranes 
to bring on a healthy action. At one time Coxe's Hive Syrup was 
largely used, either as an emetic in dram doses every ten minutes 
until it acted, or as an expectorant in the dose of 30 minims to 1 dram 
(2.0-4.0) three times a day for an adult. As it contains antimony, 
it should be given with care. 

Squill may be used as a substitute for digitalis when the latter 
remedy fails in cases of ruptured cardiac compensation associated 
with valvular disease. If after the use of squill for some days the 
urine diminishes in amount, the drug must be stopped, as this con- 
dition indicates spasm of the renal vessels or acute irritation. 

Administration.— The fluidextract (Fluidextractum Scillae, U. S.) is 
much used in the dose of 1 to 5 drops (0.06-0.3) ; the tincture ( Tine- 
turce Scilla, U. S. and B. P.) in the dose of 5 to 30 minims (0.3-2.0); 
the vinegar of squill (Acetum Scillos, U. S. and B. P.) in the dose of 
10 minims to J dram (0.6-2.0). The B. P. dose is 5-15 minims 
(0.03-1.0). The compound syrup (Syrupus Scilla? Compositus, U. S.), 
or Coxe's Hive Syrup, is composed of the fluidextract of squill, fluid- 
extract of senega, tartrate of antimony and potassium, purified talc, 
sugar, and water, and is given in the dose of 20 minims (1.3) as a 
sedative to an adult and 1 dram (4.0) as an emetic to a child. 



STILLINGIA 493 

The following prescription will be found useful in bronchitis in its 
subacute stages in a child of one to five years : 

1$ — Vini ipecacuanhse f5j (4.0) 

Tincturse scillae f3ss (2.0) 

Syrupi tolutani f 3v (20.0) 

Aquae fSj (30.0).— M. 

S. — Teaspoonful (4.0) every three or four hours. 

The plain syrup (Syrupus Scillce, U. S. and B. P.) is given in the 
dose of | to 1 dram (2.0-4.0), the honey (Oxymel Scillce, B. P.) in the 
dose of | to 1 dram (2.0-4.0), and the compound pill (Pilules Scillce 
Composite, B. P.) in the dose of 5 to 10 grains (0.3-0.6). 

STARCH. 

Amylum, U. S. and B. P., is corn starch, that is the starch grains 
of Zea mays. In very fine powder starch is used as a dusting-powder 
in intertrigo or chafing. Its more important uses are, however, in 
the form of starch-water for carrying drugs into the rectum, and in the 
form of a poultice for cases of skin diseases where it is desired to 
remove crusts. 

Starch-water is made by adding 2 tablespoonfuls of starch to 1 
pint of water, then boiling it to a paste and diluting it by the addition 
of warm water to the consistence of syrup. Starch-water is not only 
useful as a vehicle for drugs given by the rectum, but also as a sedative 
injection in proctitis and rectal irritation. 

The starch poultice is made by boiling the starch to a pasty con- 
sistence or by adding enough boiling water to a paste made by rubbing 
cold water and starch together to produce a gelatinous mass. Thirty 
grains (2.0) of boric acid to the ounce (30.0) render it antiseptic. 

STILLINGIA. 

Stillingia, U. S., queen's root, is the root of Stillingia sylvatica, 
a plant of the United States, the active principle of which is stillingin. 

Physiological Action.— There can be no doubt that this drug acts 
in two ways: first, by its immediate effects on the system, and, 
second, by its more slowly shown alterative influences. In overdose 
it causes bilious purging, increased heart action, and active secretion 
from the bronchial mucous membrane. 

Therapeutics.— Stillingia is highly recommended in habitual con- 
stipation, as it increases intestinal secretion, and it is even said to act 
as a specific in hemorrhoids dependent largely for their existence upon 
hepatic engorgement and intestinal atony. 

Bartholow recommended the following prescription under these 
circumstances : 

3 — Fluidextracti stillingiae f5v (20.0) 

Tincturae belladonna? foliorum, 

Tincturse nucis vomicae, 

Tincturae physostigmatis aa fgj (4.0). — M. 

S.— 20 drops (1.3) in water t. i. d. before meals. 



494 DRUGS 

Tincture of aloes may also be added to this prescription if constipa- 
tion is present. In syphilis of a severe type stillingia may be used 
as an aid to other drugs. 

In pasty-looking, white "putty-faced" children, who are anemic 
or strumous, and who never have any appetite, or are subject to 
middle-ear trouble and general debility, stillingia is of value. Under 
these circumstances it may be used for some time. 

The only official preparation is the fluidextract (Fluidextr actum 
Stillingia, U. S.), which should always be made of the fresh root, 
the dose of which is 10 to 60 minims (0.6-4.0). 

STOVAINE. 

Stovaine is a synthetic substance used for the purpose of produc- 
ing local anesthesia. Technically speaking it is the hydrochloride of 
alpha-dime thylamine-beta-benzoylpentonal. In other words, it has 
a chemical composition closely allied to that of the other drugs which 
cause local anesthesia. 

Stovaine appears in small, brilliant scales and is very soluble in 
water, methyl alcohol, and acetic ether. An important characteristic 
of stovaine is that it is not decomposed by boiling its solutions. 

The toxicity of stovaine when absorbed into the general system is 
said to be one-half that of cocaine. Instead of constricting blood- 
vessels in the area to which it is applied, it dilates them, and for this 
reason hemorrhage is more profuse in the wounded area when it is 
used than when cocaine is applied. When used for its anesthetic 
effect in the eye, stovaine should be dissolved in normal salt solution 
in the strength of from 1 to 4 per cent. The 1 per cent, solution is 
used for subconjunctival injections and the 4 per cent, solution for 
instillations. For local anesthesia by Schleich's method a solution of 
0.7 per cent, is used. The drug can also be employed for spinal anes- 
thesia— 15 minims (1 cc) of normal salt solution containing 1 grain 
(0.06) of the drug are injected. As a rule, however, it is best to use a 
fluid with a heavy specific gravity in order to limit the effect of the 
drug to the region in which it is injected, as, for example: stovaine, 
1 grain, glucose, 1 grain; and sterile water, 20 minims (1.3). (For 
method, see Procaine.) It is hardly necessary to state that this 
solution must be sterilized by boiling before it is injected. Untoward 
effects following this use of stovaine are said to be rarely met with, 
but when they have developed they have consisted in profuse 
sweating, vomiting, headache, and, in a few instances, relaxation of 
the sphincters. (See Cocaine and Tropacocaine.) Spinal anesthesia 
is not as safe as anesthesia produced by the careful use of ether or 
chloroform. 

STRAMONIUM. 

Jamestown weed, or Datura stromonium, is official in the form of 
the leaves (Stramonium, U. S.; Stramonii Folia, B. P.), yielding, when 



STRONTIUM 495 

assayed by the U. S. P. process, not less than 0.25 per cent, of mydri- 
atic alkaloids. It contains an alkaloid, known as daturine, which is 
physiologically identical with atropine. 

Physiological Action. — (See Belladonna.) 

Therapeutics.— The, uses of stramomium are identical with those of 
belladonna. Stramonium leaves in the proportion of 8 ounces (250) 
to 2 ounces of nitrate of potash (60) afford, when this mixture is 
burned, an efficacious method of ridding a room of mosquitoes. 

Administration.— The extract (Extraction Stramonii, U. S. and B. 
P.), containing about 1.0 per cent, of alkaloids, is used in the dose 
of £ to J grain (0.001-0.03); and the tincture (Tinctura Stramonii, 
U. S. and B. P.), containing about 0.025 gram of total alkaloids 
in 100 cc in the dose of 5 to 30 minims (0.3-2.0). The ointment 
(Unguentum Stramonii, U. S.) is also used for the same purposes as 
is belladonna ointment. The dose of daturine is y^j- to -^q grain 
(0.0005-0.0008). 

STRONTIUM. 

This metal has been introduced into medicine in the form of the 
bromide (Strontii Bromidum, U. S. and B. P.), the iodide (Strontii 
Iodidum, U. S.) the salicylate (Strontii Salicylas, U. S.), and as the 
lactate and phosphate, largely through the studies of Laborde, See, 
Paul, and others. Bromide of strontium is used for precisely the 
same effects as are the other bromides, but it is claimed that, as 
the strontium is not irritating or depressing, the disadvantages of the 
potassium salt are avoided by its employment. The dose of bromide 
of strontium is from 10 to 60 grains (0.65-4.0). In addition to the 
ordinary effect of bromides, See found the bromide of strontium to be 
useful in overcoming attacks of gastric indigestion associated with pain 
in the stomach and hyperacidity; and the author has confirmed this 
statement. The lactate of strontium seems to be indicated chiefly in 
cases of albuminuria due to renal atony. It does not increase urinary 
flow, and is said to be contraindicated in the presence of uremia and 
the high fever of acute parenchymatous nephritis. In chronic inter- 
stitial nephritis, such as is due to rheumatism or gout, it is said to be 
of value. Unfortunately, as soon as the lactate of strontium is with- 
drawn the albuminuria is apt to recur. The writer has often been 
much disappointed in the use of the lactate of strontium in albumin- 
uria, but others of wide experience seem to regard it as constant in 
producing good results. The dose of the lactate of strontium is 60 
to 100 grains (4.0-6.6) a day. 

The salicylate of strontium is a valuable preparation, because it is 
not so disagreeable to the taste as the corresponding salt of sodium; 
and, more important still, it is far less apt to disorder the stomach 
than salicylic acid or any of its other salts. The author has found it 
for these reasons very useful in acute articular rheumatism when the 
progress of the patient was delayed by the inability of his stomach 
to retain the ordinary antirheumatic remedies. The salicylate of 



496 DRUGS 

strontium is best given in capsule or cachet, and should always be 
followed by a draught of milk or water to prevent its coming in con- 
tact with the stomach in too concentrated form. The dose is, for all 
practical purposes, identical with that of the salicylate of sodium. 

Strontium possesses no toxic power whatever, and overdoses are not 
followed by unpleasant consequences. If the strontium is contami- 
nated by barium, serious effects are produced. 

STROPHANTHUS. 

Strophanthus, U. S., Strophanthi Semina, B. P., is an African plant 
(Strophanthus kombe), from the seed of which the natives make kombe 
arrow poison. There are many varieties of strophanthus. The 
active principle is Strophanthinum (U. S.), which can be obtained 
in crystalline form and a second active principle strophanthidin. 
Although Strophanthus kombe is the official plant it has been found 
that at least twenty varieties of strophanthus are on the market. 
Only three of these have been carefully studied and most of these 
investigations have naturally been on the strophanthin derived 
from S. Kombe. These three varieties are Strophanthus Kombe, 
Strophanthus hispidus, and Strophanthus gratus, and much of the 
tincture of strophanthus on the market probably comes from these 
and other sources. This would be of little importance were it not 
that even the strophanthin which is obtained from Kombe varies 
greatly quantitatively and qualitatively. It cannot be tested chemic- 
ally and Rowe has shown in twenty-two samples tested physiologically 
there was a variation so great that one was 67 per cent, of standard 
and another 240 per cent, of standard. Further than this some 
samples of strophanthin seem to be absorbed more readily than others. 
These facts probably account in part for the success of strophanthus 
in some cases and its failure in others. (See below.) 

The active principles of Strophanthus gratus is called Ouabain, 
which is sometimes used as a substitute for strophanthin. Its dis- 
advantage, according to Rowe, is the great variation in its power and 
it has not been as well studied. Like strophanthin it appears on the 
market in solution in ampoules containing 0.0005. This dose is the 
maximum. It should not be repeated oftener than once in twenty- 
four hours and is given intramuscularly, not subcutaneously or intra- 
venously. Ouabain is not official. 

It has been claimed that strophanthus contains a local anesthetic 
principle, but de Schweinitz and the author found it to be possessed 
of this power only in dogs, and not in man. 

Physiological Action.— Strophanthus acts as a stimulant to the heart 
muscle, but does not slow the pulse by an action on the vagi, as does 
digitalis. While it raises arterial pressure by the increased heart 
action, it does not stimulate the vascular system to any extent. It 
is, therefore, useful in cases of weak heart with arterial spasm, since it 
helps the heart, but does not increase its work by raising arterial 
tension. 



STROPHANTH US 497 

Therapeutics.— Strophanthus may be used to supplant digitalis in 
all forms of cardiac disease, but it is not its equal, and it is to be recalled 
that so large a part of the active principles of the drug is destroyed 
in the alimentary canal that the use of the drug by the mouth is an 
uncertain method of medication. Furthermore it is very slowly 
absorbed and so its effects are uncertain, and if the doses are large it 
is prone to produce an active diarrhea. The fact that the dose of 
the tincture is about the same as tincture of digitalis, although the 
amount of strophanthin it contains makes it about 150 times as toxic 
if it is tested upon the frog's heart, proves that only a little of it is 
really absorbed, and when doses as small as 5 minims (0.3) are given 
any benefit comes from other factors. 

Strophanthus is often better than digitalis in cases of weak heart 
with high arterial tension, as it exerts no effect upon the bloodvessels, 
as does digitalis. 

As is well known, there are a certain number of cases in which 
digitalis fails to do good, the explanation being that under such cir- 
cumstances the transmission of impulses over the bundle of His is 
delayed or arrested by its influence. Strophanthus often acts exceed- 
ingly well in these instances where digitalis fails. It will relieve 
cardiac dropsy by its action on the heart, but does not possess marked 
diuretic properties. t Intravascular injection of strophanthin is a cer- 
tain method of getting the effects of the drug, but subcutaneous injec- 
tion is ill advised, owing to its local irritant effects. Possibly because 
the heart, under an intravenous injection, gets the whole of the dose 
used, it is a fact that the effect of the drug so given is not only more 
marked but also much more prolonged. Intravenous injections 
should, however, be given only in very urgent cases of failing heart. 

A very useful preparation is strophanthone. It is active and 
prompt in its effects and should be employed from ampoules contain- 
ing 2| minims (0.15) diluted with normal saline to 16 minims (1.0). 
This may be given hypodermically or by the mouth in the dose of 
J to 1 cc or intravenously in the dose of \ cc. One cc represents 
about ^5 of a grain of strophanthin, so that \ cc (about 7 drops) will 
often be sufficient. Its effects often persist, when given by the needle 
for twenty-four hours. 

Untoward Effects.— Strophanthus when given in full doses by the 
mouth often causes diarrhea. It is important to bear in mind that after 
full doses of digitalis have been given a fatal result may follow the intra- 
venous use of strophanthin. Several days should elapse after digitalis 
is stopped before the strophanthin is given. 

Administration.— Strophanthus is given in the form of tincture 
(Tinctura Slrophanthi, U. S., and B. P.), in the dose of 5 to 15 minims 
(0.3-1.0) (5 minims (0.3), B. P.), three times a day. The extract of 
strophanthus {Extr actum Strophanthi) is now official in the B. P. 
The dose is \ grain (0.015). Strophanthin (Strophanthinum, U. S.), 
may be given intravenously in the dose of T ^ grain (0.0004). 
32 



498 DRUGS 



SUGAR. 



Saccharum, U. S. (Saccharum Purification, B. P.), is the refined 
juice of Saccharum officinarum, or sugar-cane, or that obtained from 
Sorghum, or from the sugar-beet. It is an antiputrefactive, but not an 
antifermentative. Mixed with iron preparations, it prevents oxida- 
tion. As it is a hydrocarbon, it is a nutrient and a developer of adi- 
pose tissue, or, in other words, is a food. Its use is contraindicated in 
obesity, during the existence of fermentative changes in the stomach 
and intestine, and in diabetes mellitus. 

SUGAR OF MILK. 

Saccharum Lactis, U. S. and B. P., is derived from the whey of 
cows' milk by evaporation, in the proportion of about 5 per cent., and 
is then purified by re-crystallization. It has little sweetening power 
compared to cane-sugar and possesses a peculiar insipid taste. It is, 
however, less apt to ferment and is better for infants than is cane-sugar. 

Milk-sugar is largely used in triturations, because by its hardness 
it aids in the subdivision of the medicament. It is also used to in- 
crease the bulk of small powders when such drugs as podophyllin and 
calomel are prescribed. It is sometimes called lactose. 

Lactose to be possessed of great diuretic power should be given in 
full doses. The advantage claimed for lactose as a diuretic is its direct 
action on the kidney and the slight effect exercised upon the rest of the 
organism. It is, therefore, in cardiac dropsy or renal inactivity that 
this substance is particularly indicated. The dose of lactose in cases 
of dropsy should be as great as from 2 to 4 drams (8.0-16.0), given 
daily, dissolved in a quart (960 cc) of water. It has been found 
that the lactose acts best in those cases in which there is little 
albuminuria. The diuretic effect is of interest in view of the well- 
known clinical fact that the too free addition of lactose to the milk 
of bottle-fed babies always causes profuse diuresis. 

SULPHONAL. 

Sulphonmethanum, U. S., Sulphonalum, B. P., is a synthetically 
prepared substance first manufactured in Germany by Baumann, and 
possesses the chemical name of die thy 1-sulphone-dime thy 1-me thane. 
It is a colorless, odorless, solid substance, soluble in 365 parts of cold 
and 16 parts of boiling water, and in 60 parts of alcohol and 64 of 
ether. The drug is not affected by any of the ordinary acids, and is 
very stable. 

Physiological Action.— In medicinal doses the effect of sulphonal 
upon the . lower nervous system is practically nil. The dominant 
effect is on the brain. The drug is completely changed during its 
passage through the body. On the circulation the drug has but little 
effect; upon the respiration it acts as a depressant only when given in 
very full doses. 



SULPHIDE OF CALCIUM 499 

Therapeutics.— Sulphonal finds its place in medicine as a somni- 
facient or hypnotic, valuable when functional nervous insomnia is 
present, useless where advanced disease, such as cardiac trouble, is 
responsible for the wakefulness. In insanity it often produces sleep, 
and is of great service in the various mental disturbances character- 
ized by lack of sleep and often affecting persons of unsound mind. 
Sulphonal is not as useful an hypnotic as barbital or barbital sodium. 
It possesses sleep-producing power of moderate amount— not equal 
to chloral, but greater than that of paraldehyde— and it will some- 
times succeed where the other hypnotics fail. It has the great 
advantage of not being a depressant to the heart. 

Administration.— Sulphonal being virtually insoluble in cold water, 
may be given in large capsules or in mucilage of acacia, so as to be 
held in suspension until swallowed. The insolubility and bulki- 
ness of the drug render its use difficult. It is best given in hot water 
(about 6 ounces), as suggested by Stewart. This makes a solution, 
and as soon as the liquid is cool enough to be swallowed it should be 
taken before precipitation occurs as the result of cooling. Sulphonal 
should be used several hours— say two or three— before the patient 
retires. If taken late at night, the patient frequently fails to sleep 
until the morning hours, and is heavy and drowsy all the next day. 
This difficulty is partly avoided by the use of a hot solution, but even 
then it is apt to arise. The dose is 20 to 40 grains (1.3-2.6). It is 
wise not to use sulphonal continuously for more than a few days. 

Untoward Effects.— When sulphonal is taken in full dose for long 
periods of time, great sleepiness and weariness, with an unsteady 
gait, develop, which may go on to paralysis of the lower extremities 
if the use of the drug is persisted in. In some cases the paralysis is 
progressive, and in others hyperesthesia and abnormal sensations 
develop. In many such cases there is great disturbance of digestion 
with scanty secretion of urine, which contains an unusual substance, 
giving this secretion the color of port wine (hematoporphyrinuria) . 
This is partly due to a cumulative effect of the drug. 

Sulphonal often produces mental heaviness and a staggering gait 
the day after it is taken in a single dose. This can to some extent 
be avoided by giving a dose of some laxative when the drug is taken, 
so that the bowels will be moved thoroughly the next morning. There 
are a number of cases of death on record from acute and chronic 
poisoning by sulphonal. In both classes of cases the death was by 
respiratory failure preceded by profound unconsciousness. As much 
as 120 grains (8.0) have been taken, however, without ill effect, and 
Neisser has reported a case which recovered after 1400 grains had 
been taken. Probably but a small amount of this dose was actually 
absorbed. In cases of subacute or chronic poisoning the prognosis 
is unfavorable if the symptoms are well developed. 

SULPHIDE OF CALCIUM. 

(See Calcium, Calx, and Sulphides.) 



500 DRUGS 



SULPHUR. 



Sulphur is a non-metallic element official in four forms in the 
U. S. P.— namely, as Sulphur Sublimatum, U. S. and B. P., or sub- 
limed or flowers of sulphur; Sulphur Prcecipitatum, U. S. and B. P., 
or precipitated sulphur; Sulphur Lotum, U. S., or washed sulphur. 

Much confusion exists among students as to the differences between 
these various forms of sulphur. Sulphur itself is an element which 
is prepared for medicinal uses by being heated and sublimed (Sulphur 
Sublimatum), or flowers of sulphur. Sulphur lotum, or washed sul- 
phur, is prepared in order to get rid of sulphuric acid and other con- 
taminating substances, and is made from sublimed sulphur. Sulphur 
prcecipitatum is also made from sublimed sulphur, and is more bland 
and minutely subdivided. Some believe it differs from sublimed 
sulphur in its therapeutic properties by reason of a small amount of 
water supposed to be present. It is sometimes called milk of sulphur. 
When sulphur is prescribed for internal use the sublimed sulphur is 
generally designated. 

Physiological Action.— Sulphur has little physiological influence over 
the general system. When taken internally it causes a soft, mushy 
stool of a yellow color which often has a strong odor of hydrogen 
sulphide. The drug acts particularly on the skin and mucous mem- 
branes as a gentle alterative. The juices of the intestines break up 
some of it into sulphuretted hydrogen and sulphides. 

Therapeutics.— Sulphur is used as a mild laxative, never as a purge. 
In stricture of the bowel the soft stools produced by it will often slip 
by the obstruction, and it is worthy of note that sulphur will some- 
times overcome constipation when nothing else will give relief. It is 
particularly valuable in the treatment of constipation where there 
are hemorrhoids, and in chronic rheumatism and sciatica it is thought 
by some to effect a cure. 

Sulphur is of service in the treatment of chronic bronchial affec- 
tions, but for some curious reason its use has become almost obso- 
lete. Graves recommended 5 to 10 grains (0.3-0.6) of sulphur 
three times a day wherever bronchial secretion was excessive, and 
found that it rid the lungs of mucus and relieved the cough. 

The external use of sulphur is very much more important than its 
internal use, in so far as regards affections of the skin. Of itself, 
the drug exercises little effect over the cuticle when used in powdered 
form, but combination with an ointment makes it at once active. 
Even irritations of the skin may ensue from its constant use in large 
amount. 

In scabies, or itch, sulphur ointment (Unguentum Sulphuris, U. S. 
and B. P.) is the best remedy we have. The female parasite burrows 
under the epiderm and deposits the ova as she moves about, while the 
male does not burrow, but stays on the surface. The ointment will 
kill him, as he is readily attacked, but the female is protected by her 



SULPHURIC ACID 501 

burrowing propensities. To get at her and the ova the burrows must 
be opened, and this may be accomplished by a thorough soaking of 
the body with soap and water, thereby softening the epiderm covering 
the parasite, which can then readily be removed by rubbing the 
patient with a rough towel. The towel should be boiled at once to 
prevent its conveying the parasite to others. The ointment, if now 
applied, relieves the patient almost at once. It is important that the- 
skin be well softened and rubbed, in order to keep open every burrow. 
The ointment should be allowed to remain on the part all night and be 
used for three or four nights consecutively. 

Young women often suffer from acne, particularly about the men- 
strual epoch, the skin also becoming at this time sallow and muddy. 
The following ointment is one which is very successful in promoting 
a cure: 

1$ — Sulphuris prsecipitati 5j (4.0) 

Adipis lanse hydrosi 5j (30.0). — M. 

S. — Apply once or twice daily. 

Administration.— Sulphur is given in the dose of 10 to 20 grains 
(0.6-1.3) three times a day as an alterative, and from 1 to 2 drams 
(4.0-8.0) at night as a laxative, with a little molasses to form a paste. 

A confection (Confectio Sulphuris) is official in the B. P., dose 10 
grains to 2 drams (0.6-8.0), as is also Trochiscus Sulphuris. 



SULPHURIC ACID. 

Acidum Sulphuricum, U. S. and B. P., sulphuric acid, or oil of 
vitriol, is a powerful irritant and escharotic, rapidly dehydrating and 
carbonizing the tissues, causing them to become black. It is the 
most astringent of the medicinal mineral acids, and when absorbed 
it unites with bases to form sulphates, and is so eliminated by the 
kidneys, the lower bowel, and the skin. It coagulates albumin. 

Poisoning.— The symptoms produced by poisonous doses are those 
of a gastro-intestinal inflammation of the most severe type, or the 
patient may drop to the floor almost at once, owing to collapse depend- 
ent upon perforation of the walls of the esophagus or stomach by 
the acid and its consequent escape into the peritoneal cavity. If the 
patient lives to the fourth day, the parotid glands may become 
swollen as the result of stenosis of the salivary ducts of Stenson, and 
violent inflammation of the kidneys may appear from the passage of 
the drug through these organs in the process of elimination. If 
partial recovery takes place, the patient often dies from inanition 
due to the formation of strictures in the alimentary canal or to 
destruction of the peptic tubules. The stain about the mouth is 
black, and if any of the acid is spilt on the clothing, the characteristic 
burn is to be seen. 



502 DRUGS 

The treatment consists in the use of alkalies, such as chalk, mag- 
nesia, whitewash off walls, and soap. Opium and oils are to be given 
to allay irritation, and external heat is to be applied. 

Therapeutics.— Sulphuric acid is sometimes employed as a caustic 
to venereal sores, warts, and slowly healing ulcers, but is most com- 
monly used internally, as it fulfils several pressing indications. As 
a remedy for serous diarrhea, particularly if combined with some 
vegetable astringent, it is unsurpassed, and its use in cholera deserves 
great attention. (See Diarrhea.) In the Philadelphia Hospital dur- 
ing an epidemic of cholera some years since every patient who 
received sulphuric acid improved or failed to be attacked, whereas 
those who did not receive it were either very ill or died. 

The proper way to use the drug as a prophylactic during cholera 
epidemics is in the form of " sulphuric-acid lemonade," made so that 
each wineglassful of water contains 5 drops (0.3) of the aromatic 
sulphuric acid. The same solution may be used in acute lead 'poison- 
ing in order to form an insoluble sulphate of lead, and may be taken by 
artisans exposed to chronic lead poisoning as a prophylactic for the 
same purpose. 

Sulphuric acid combined with belladonna or atropine is often used 
in the night-sweats of phthisis. 

Administration. —The dose of the dilute acid (Acidum Sulphuricum 
Dilutum, U. S. and B. P.), is 5 to 20 minims (0.3-1.3), and of the 
aromatic acid {Acidum Sulphuricum Aromaticum, U. S. and B. P.) 
5 to 20 minims (0.3-1.3). The latter is the best preparation for 
general use. It contains tincture of ginger and oil of cinnamon. 
Both preparations should be thoroughly diluted before they are 
administered and taken through a tube. 



SUMBUL. 

Sumbul, U. S., is a root of undetermined origin. The dose of the 
root (Sumbul Radix, B. P.) is 10 to 40 grains (0.6-2.6). On the 
nervous system sumbul acts as an efficient nerve tonic, and was largely 
employed by Goodell in cases of nervous exhaustion and in the unrest 
of nervous females. It is official in the fluidextract (Fluidextractum 
Sumbul, U. S.), dose 5 to 20 minims (0.3-1.3), and the extract (Ex- 
tractum Sumbul, U. S.), dose 1 to 5 grains (0.06-0.3). The tincture 
(Tinctura Sumbul, dose 1 to 4 drams (4.0-16.0) is official in the B. P. 
Goodell used the following formula: 

]$ — Extracti sumbul gr. xx (1.3) 

Ferri sulphatis . gr, xx (1.3) 

Asafcetidse . gr. x (0.6) 

Arseni trioxidi gr. £ (0.03).— M. 

Fiant pilulae, No. xx. 

S. — One t. i. d. after meals. 



SUPRARENAL GLAND AND ADRENALIN 503 



SUPRARENAL GLAND AND ADRENALIN. 

The dried suprarenal gland, Suprarenalum Siccum or its active 
principle, adrenalin (Adrenalinum B. P.), has become within the last 
few years one of our most valued remedies. Its chief use in medicine 
depends upon its extraordinary power of producing contraction of 
small bloodvessels and capillaries with which it is brought in contact. 
It also exercises a marked constricting effect on the bloodvessels of the 
general arterial system when given intravenously but chiefly affects 
the vessels in the splanchnic area. (See below.) 

The medullary portion of the glands is chiefly concerned with 
the elaboration of the active physiological principle, which was 
isolated by a Japanese chemist, Takamine, and called adrenalin. 
Adrenalin occurs in tiny, almost microscopic, white crystals of various 
forms. As adrenalin is not readily soluble in water, adrenalin 
chloride is always employed and appears on the market in solution in 
the strength of 1 to 1000. As this strength is too great for local appli- 
cation in most instances it is further diluted before use by water or 
salt solution, even to 1 in 20,000. These dilute solutions are readily 
oxidized if exposed for a length of time to the air, becoming pink, then 
red, and finally brown in color when they lose their efficiency. When 
in ampoules adrenalin chloride solutions can be sterilized by boiling 
without any loss of activity. In unsealed solutions exposed to the air 
such solutions can be sterilized by boiling once or twice without loss 
of power. 

It is important to bear in mind that adrenalin given by the stomach 
is destroyed and has practically no effect on the general system. To 
be effective on the general system it must be used intravenously or 
hypodermically. Its physiological effects when secreted by the supra- 
renal bodies are somewhat different from those when it is injected 
en masse. Thus when secreted freely it causes a flooding of the 
blood with stored glycogen and thereby provides the muscular system 
with more food when it is needed; it increases the flow of blood to the 
heart, lungs, central nervous system and the limbs and at the same 
time diminishes the blood supply to the digestive organs. While 
these are its chief physiological effects when secreted they are rarely 
sought for when the substance is used as a therapeutic agent. 

The following may be said to be the physiological effects sought or 
desired when it is used medicinally either locally or by the needle. 

Physiological Action.— When locally applied to mucous membranes 
extract of this gland, or adrenalin, produces great blanching by reason 
of its powerful constriction of the capillaries of the part. So great 
is this constriction that the superficial tissues are practically blood- 
less while its influence lasts. This local effect is due to stimulation 
of the muscular fibers in the bloodvessel walls. Its use is not followed 
by so great a relaxation and congestion as is seen as a secondary effect 
after the local application of cocaine to a mucous membrane. Given 



504 DRUGS 

intravenously, it slows the pulse by the increased arterial pressure 
which is due to the contraction of the muscular coats of the blood- 
vessels and by increasing the activity of the vagi. It also increases 
the force of the heart systole by its effect on its muscle fibers, but the 
effects are very fleeting. The brevity of these effects is not due to a 
rapid destruction or elimination of adrenalin, but rather depends upon 
its inability to maintain its primary influence. This is proved by the 
fact that if the bloodvessel going to a limb is ligated, thereby cutting 
off its blood supply, and adrenalin is injected into the vessels of the 
rest of the body, it causes a contraction of all the bloodvessels except 
those in the ligated part. If after its effects upon the general vascular 
system have disappeared, the ligature is removed, so permitting the 
blood to enter the limb, the bloodvessels in the hitherto protected 
part undergo powerful constriction, which proves that there is still 
active adrenalin in the circulating fluid. The constriction of the 
bloodvessels is due to the action of the drug on the vessel walls and 
not to a centric vasomotor influence. 

Upon the venous system, when not locally applied, its effects may 
be ignored. It also increases the force of the systole of the heart 
by stimulating its muscular fibers and slows the pulse by increasing 
the activity of the vagi. In other words, the effect of adrenalin upon 
the circulatory system is very similar to that of digitalis, but is more 
immediate and fleeting. It is important to recall the fact that the pul- 
monary vessels are not affected by adrenalin, and that even the direct 
application of this substance to the lung does not cause local ischemia. 
Although it constricts the fibers of the systemic bloodvessels it relaxes 
the bronchial muscularis. Further, the constricting effect on the 
vessels of the cerebrum is very slight. The vessels of the uterus are 
strongly affected, but those of the bladder are but slightly influenced. 

When injected in full dose beneath the skin or into a vein adrenalin 
causes a temporary glycosuria in many cases because the blood is 
flooded with sugar. 

Therapeutics.— Because of its extraordinary power in constricting 
bloodvessels of small caliber adrenalin is a remedy in all forms of 
hemorrhage from such vessels, if it can be locally applied. 

Thus, it can be employed locally in epistaxis, menorrhagia, metror- 
rhagia, and for the purpose of controlling hemorrhage in operations 
on the nose, throat, ear, or larynx. It can also be employed to relieve 
the engorgement of the nasal mucous membrane in cases of asthma, 
coryza, and hay fever, and in trachoma and conjunctivitis. 

An acute attack of bronchial asthma can sometimes be rapidly and 
completely relieved by the hypodermic injection of 5 to 10 minims 
(0.3-0.6) of adrenalin solution, 1 : 1000 strength {Liquor Adrenalini 
hydrochloride B. P. This is due to the fact that adrenalin relaxes 
the muscular fibers of the bronchi. So too, an intramuscular injection 
of 10 to 15 minims (0.65-1.0) may be given in pulmonary edema 
sometimes with advantage. (See Pituitrin.) In sudden cardiac 



SUPRARENAL GLAND AND ADRENALIN 505 

failure and collapse complicating surgical procedures, a pint of normal 
saline solution may be slowly injected into a large vein, and in this 
solution, as it flows into the vessel through a rubber tube, should 
be placed 30 minims (2.0) of adrenalin solution (1 : 1000). Cases ap- 
parently moribund have been resuscitated by this means. It is also 
very valuable when given hypodermically in anaphylaxis. Recent 
investigations have seemed to show that adrenalin very distinctly 
increases the tendency to the ventricular fibrillation which is induced 
by chloroform and it would seem to be proved that after adrenalin 
has been used locally or hypodermically, chloroform as an anesthetic 
is distinctly contr abdicated. 

It has also proved itself a valuable agent in controlling surgical 
shock. Under these circumstances the vasomotor center is depressed 
or paralyzed and death ensues because of the vascular relaxation. The 
use of strychnine for the purpose of stimulating the vessels through 
the vasomotor center is often useless because it is too depressed to 




•frpir-^rpjryjjyypjrtjy-z^^ 

Fig. 65. — Showing the rise of arterial pressure produced by the injection of 0.00004 
of adrenalin into the vein of a dog. 

respond. The intravenous injection of adrenalin acts directly upon 
the muscular fibers in the vessel walls and raises blood-pressure so 
that life is saved. When adrenalin is used in this way the ordinary 
1 : 1000 solution in which it appears on the market should be added 
to the extent of 1 to 2 drams (4.0-8.0) to a pint of normal saline 
solution and slowly given intravenously or by hypodermoclysis. 
Strong solutions should not be used hypodermically in infectious 
diseases because they cause ischemia of the part injected, and this, 
in turn, permits germs to grow, and so a slough may ensue. 

Adrenalin is largely and wisely used in association with local anes- 
thetics, such as cocaine, etc., to increase their local effect by confining 
them to the part to which they are applied, and it greatly diminishes 
the danger of their absorption into the system by diminishing the 
blood supply of the part to which it is applied. 

Certain clinicians also assert that the injections of 5 to 15 minims 
(0.3-1.0) of adrenalin solution, 1 : 1000, into inoperable sarcomatous 
and carcinomatous growths results in a marked arrest in the develop- 



506 DRUGS 

ment of the tumor and in a gain in weight on the part of the patient. 
If the injection causes pain it may be preceded or accompanied by 
procaine. In pernicious vomiting of pregnancy, without albumin- 
uria, 20 minims (1.3) of the 1 : 1000 solution in salt solution may be 
given hypodermically with advantage in some cases. 

Adrenalin is used in the dose of 0.5 cc of the 1 : 1000 solution, 
given hypodermically, to aid in the diagnosis of early hyperthyroidism 
since when the thyroid is hyperactive the nerve endings in the sym- 
pathetic system are sensitized to its effects. The blood-pressure 
and pulse-rate is taken before the injection and thereafter every three 
minutes over a period of ninety minutes. If there is hyperthyroidism 
the pulse-rate and pressure both rise about ten points within the first 
fifteen minutes with heart consciousness, a feeling of dread, tremor, 
pallor and flushing with some sweating. This so-called Goetsch test 
not only diagnosticates hyperthyroidism, but aids us in separating the 
fag of early tuberculosis from the condition in which too great 
activity of the thyroid exists. Unfortunately the test sometimes fails. 

The Loewi test consists in dropping into the eye one or two drops of 
the 1 : 1000 solution of adrenalin, when if there be pancreatic insuf- 
ficiency the pupil will dilate at once. 

Administration.— Suprarenal gland may be given in desiccated form 
Suprarenalum Siccum, U. S.) in the dose of 3 to 10 grains (0.2-0.6), or 
as an extract of the gland, in the dose of 3 to 5 grains (0.2-0.3) three 
times a day or of tener. As already stated its effects when given by the 
mouth are practically nil. By far the best form in which to use it is 
adrenalin chloride in normal salt solution, 1 : 10,000 to 1 : 1000 (Liquor 
Adrenalinum Hydrochloricus, 1 to 1000, B. P.). Adrenalin may be 
given internally in solution to check hemorrhage from the stomach, 
but if it is being used in a case of shock its action by this method 
is too feeble for the gastric juice certainly diminishes its activity or 
destroys it before it can be absorbed. When used locally it is 
employed by wetting a pledget of cotton with the solution named and 
then pressing it lightly against the part which it is desired to affect. 
Blanching comes on in a few moments. A solution of 1 : 10,000 or 
stronger may also be brought in contact with the part by means of an 
atomizer. 

SWEET SPIRIT OF NITRE. 

Sweet spirit of nitre (Spiritus Mtheris Nitrosi, U. S. and B. P.), or 
spirit of nitrous ether, is a mixture of alcohol, water, and ethyl nitrite. 
Spirit of nitrous ether should contain not less than 3.5 percent, of ethyl 
nitrite. It is upon this last constituent that most of its value as a 
remedial agent depends. The drug when sold by pharmacists or others 
who are not careful to keep fresh preparations is no better than alcohol 
and water alone, since the ethyl nitrite readily escapes, and deteriora- 
tion at once takes place. When freshly prepared and medicinally 
active this preparation should, as its name indicates, be sweet in taste. 



SWEET SPIRIT OF NITRE 507 

If it is acid, turns blue litmus red, or effervesces on the addition of 
bicarbonate of potassium or sodium it should be rejected. When 
sweet spirit of nitre is impure because of the presence of free acid, and 
is mixed with antipyrine, a purple color followed by a green precipi- 
tate will be formed. This green precipitate is iso-nitroso-antipyrine, 
which is not in the least poisonous, but such a sample of nitre should 
be discarded. 

Physiological Action.— Sweet spirit of nitre is a sedative to the cir- 
culatory and nervous systems, as are all the nitrites (see Nitrite of 
Amyl) and a diaphoretic and diuretic, according to the manner in 
which it is administered. If given in very full doses, it rapidly 
produces the cyanosis characteristic of the full effects of any one of 
the nitrites. (See Amyl Nitrite.) 

Therapeutics.— There is probably no drug so widely employed by 
the laity as a household remedy which is so potent for good, and yet 
so harmless, if wrongly used, as is this one. 

Physicians often place less reliance upon it than it deserves, and 
in nearly every instance where it fails it is either not indicated or the 
nitrous ether has escaped and left it powerless. 

In incontinence of urine in children the combination which follows 
is very useful in certain cases. (See also Incontinence of Urine, Part 
IV.) In these instances the urine will be found high-colored, acid, and 
concentrated, and therefore capable of irritating the bladder and 
genito-urinary tract: 

3— Potassii citratis 3J to 3ij (4.0-8.0) 

Spiritus setheris nitrosi foss (16.0) 

Aquae destillatse q. s. ad f5iv (120.0). — M. 

S. — Dessertspoonful (8.0) every five hours until the urine becomes clear. 

As soon as the urine is clear and neutral, belladonna may be used, 
the citrate of potassium and sweet spirit of nitre being continued or not 
as the case demands. When the spinal centers are depressed and there 
is general atony of the system, it may be well to substitute the fol- 
lowing pill for the belladonna: 

3— Arseni trioxidi gr. | (0.012) 

Extracti nucis vomica? gr. ij (0.12) 

Quininse sulphatis gr. xx (1.3). — M. 

Fiant pilulse, No. xx. 

S. — One pill t. i. d. after meals. 

The diuretic action of sweet spirit of nitre is best obtained by using 
the drug in ice-cold water and keeping the patient lightly covered 
and cool. On the other hand, if a diaphoretic influence is desired, 
it may be given simultaneously with warm lemonade, and the patient 
should be well blanketed. This last action of sweet spirit of nitre 
has made it a remedy of common use in treating acute colds in adults 
and children, and in diminishing the fever of these conditions in the 
latter class as well. 



508 DRUGS 

Sweet spirit of nitre is a distinct antispasmodic, and can be well 
employed where slight nervous excitement accompanies fevers or in 
other states associated with nervous irritation in infancy. 

The dose for an adult is from 20 minims to 2 drams (1.3-8.0), 
and for a child of one year 5 to 10 minims (0.3-0.6). It should 
always be given in cool water to the latter class of patients. 

TAMARINDS. 

Tamarindus, B. P., is the preserved pulp of Tamarindus indica, a 
tree of the West Indies. 

The taste is a peculiar mixture of bitter and sweet. As a laxative 
it exerts little power over that of any ordinary fruits, such as apples, 
but it enters into the confection of senna (Confectio Sennoe, U. S. and 
B. P.). Patients often find tamarinds a very agreeable laxative when 
they are taken before going to bed or eaten as a confection after meals. 

TANNIC ACID. 

Tannic acid (Acidum Tannicum, U. S. and B. P.) when pure is 
an uncrystallizable, white or yellowish-white powder, without bitter 
taste and very soluble in water and glycerin. It is not soluble in 
alcohol or ether. It is the chief active principle of vegetable astring- 
ents, and occupies the relative position of an alkaloid to a crude drug, 
so far as the active portion of these vegetable astringents is concerned. 
Tannic acid is derived from nut-gall. 

Physiological Action. —Tannic acid when brought in contact with 
any of the tissues of the body constringes them and decreases their 
vascularity for a time, by causing contraction of their bloodvessels. 
For these reasons it stops secretion and constringes parts of the body 
which are relaxed and feeble. Mixed with blood, it forms a clot with 
great rapidity through coagulation of the albumin. Tannic acid is 
absorbed as gallic acid and eliminated as such, only acting as tannic 
acid before absorption. This is important to remember, since we 
learn from this that tannic acid is to be used to check hemorrhage 
only where the drug can be brought in direct contact with the bleed- 
ing point. 

Therapeutics.— Tannic acid is used in medicine to control hemor- 
rhage, and to act as an astringent to relaxed tissues, as in diarrhea 
of the atonic or serous type, or in localized or general sweating. It 
is also of service for the purposes of toughening mucous membranes 
or parts of the skin which are exposed to much rubbing, as in the 
case of the nipples of a primipara, or where the feet become macer- 
ated and sore or sweat profusely on exercise being taken. (See 
Formaldehyde.) In the treatment of hemoptysis tannic acid may be 
dissolved in water in the proportion of 5 to 10 grains (0.3-0.6) to 
the ounce (30.0) and used in a fine spray delivered from an atomizer, 



TAR 509 

but it is of little or no value because it does not reach the bleeding 
point. 

Glycerite of tannin is made by adding 2 ounces (60.0) of tannic acid 
to a | pint (240 cc) of glycerin, and mixing at a gentle heat until 
solution occurs. It is useful as an application to indolent ulcers and 
depressed mucous membranes, as after an attack of stomatitis. In 
hemorrhoids of the bleeding type tannic-acid suppositories are often 
very useful, and cotton saturated with tannic-acid solution is often 
used as a packing in vaginal leucorrhea. 

Administration.— The dose of tannic acid is 2 to 10 grains (0.12- 
0.6), best given in pill. The official preparations are— the troches 
(Trochisci Acidi Tannici, U. S.), each containing 1 grain of tannin; 
the Gly centum Acidi Tannici, U. S.; Collodium Stypticum, U. S.; 
and an ointment ( Unguentum Acidi Tannici,^]. S.). The B. P. pre- 
parations are— Glycerinum Acidi Tannici; Suppositoria Acidi Tannici, 
each containing 3 grains (0.20); and Trochiscus Acidi Tannici, of 
which each contains \ grain (0.30) of the acid. 

TANSY. 

Tansy (Tanacetum) is the leaves and tops of Tanacetum mlgare, 
yielding a volatile oil (Oleum Tanaceti) which possesses emmenagogue 
powers and has been largely used as a uterine stimulant. It is also 
used as an anthelmintic. 

In poisonous dose it causes epileptiform convulsions in some cases, 
and deep coma, with death from respiratory failure. 

The dose of the oil as an emmenagogue is 1 to 3 drops (0.06-0.2). 

In domestic medicine tansy tea, made by adding 1 ounce (30.0) of 
the leaves or tops to 1 pint (480) of hot water, and given in the dose 
of 1 to 2 ounces (30.0-60.0), is largely employed as a remedy for 
amenorrhea. 

TAR. 

(See Pitch, p. 448). 

Under the name of Pix Liquida, U. S. and B. P., or tar, we have an 
empyreumatic oleoresin obtained by destructive distillation from 
Pinus palustris (Syhestris, B. P.) and other varieties of pine. It is a 
thick, dark oil, slightly soluble in water and soluble in alcohol, oils, 
and solutions of potassa and soda. By distillation of tar we obtain oil 
of tar (Oleum Picis Liquidce Rectificatum, U. S.), which is used in 
bronchitis by inhalation from an atomizer, but is not a particularly 
useful application. It should be diluted with some other oil or with 
liquid petrolatum. Tar itself is used in subacute and chronic bronchitis 
in 2-grain (0.12) pills, and as a remedy for g astro-intestinal catarrh. 
Externally, it is used in psoriasis and other skin diseases needing 
stimulation. For the relief of obstinate diarrhea Wood has highly 
recommended a mixture of tar made as follows: Add a pint of tar 



510 DRUGS 

to a gallon of lime-water, and allow this solution to stand one week, 
stirring it every few hours. Decant the clear liquid and percolate 
it through powdered wild-cherry bark, allowing 1 ounce of the bark to 
be present for each pint passed through it. The dose is a wineglassful 
(60.0). 

In chronic bronchitis tar-water is largely used, as a popular remedy, 
in Europe and England. Tar-water is made by shaking 1 part of 
tar with 4 parts of water several times during twenty-four hours, 
decanting, and filtering. The dose is from 1 to 2 pints (J-l liter) 
a day as a drink. It at first increases the expectoration, but finally 
decreases it. 

Syrup of tar (Syrupus Picis Liquidce, U. S.) is simply sweetened 
tar-water. 

In skin diseases of the dry, scaly sort, such as psoriasis, tar oint- 
ment (Unguentum Picis Liquidce, U. S. and B. P.) is very useful if 
frequently applied, or the following may be used: 

]$ — Sulphuris prsecipitati, 

Picis liquidse aa 3vj (24.0) 

Saponis viridis, 

Adipis aa Sij (60.0) 

Pulveris cretae 3iv (16.0) 

If the skin is tender, this prescription should be diluted with lard. 
Sometimes children will suffer from a persistent dry chronic eczema 
which resists all treatment; the following may then be employed with 
advantage. 

I^— Picis liquidse 3ss (2.0) 

Sulphuris prsecipitati 5ss (2.0) 

Unguenti zinci oxidi 5j (30.0) 

S. — Apply night and morning. 

Tar should not be used on the face, as it will stain the skin. 

Wine of tar (Vinum Picis) is made by adding together tar 1 pint, 
glycerin, white wine, and honey of each J a pint, dilute acetic acid 
1 ounce, and 3 parts of boiling water, and shaking constantly at a 
temperature of 160° F. for several hours. This mixture is then set 
aside for some days and repeatedly filtered or strained through muslin. 
The dose is 1 to 4 ounces (30.0-120.0). It may be used instead 
of tar-water or tar-syrup. 

TARAXACUM. 

Taraxacum, U. S., Taraxici Radix, B. P., dandelion, is a very old 
remedy for hepatic torpor and the dyspepsia resulting therefrom. It 
should be prepared from the fresh leaves or roots, as the dried plant 
is inert. From disregard of this fact much disappointment has arisen. 
Owing to its being bitter it acts as a tonic. The extract (Extractum 
Taraxaci, U, S. and B. P.), dose 5 to 30 grains (0.3-2.0), and the 



TERPINE HYDRATE 511 

fluidextract (Fluide.xtractum Taraxaci, U. S., dose 1 to 3 drams 
(4.0-12.0), are the only official preparations. Succus Taraxaci, B. P., 
is given in the dose of 1 to 2 drams (4.0-8.0). 

TARTARIC ACID. 

Acidum Tartaricum, U. S. and B. P., is derived from crude potas- 
sium bitartrate, and is much less powerful than acetic acid, but cap- 
able of producing very severe gastro-enteritis if taken in overdose and 
in concentrated form. It is rarely used alone, and is most commonly 
employed to act upon sodium or potassium bicarbonate to form effer- 
vescent drinks. (See Seidlitz Powder and Effervescing Draught.) 
The dose is 5 to 10 grains (0.3-1.3). 

When tartaric acid is taken in poisonous dose, lime-water, alkalies, 
and magnesia are the antidotes, and opium is to be given to allay 
irritation. If necessary, emetics are to be used. 

TEREBENE. 

Terebenum, U. S. and B. P., is a clear, thin, colorless liquid, slightly 
insoluble in water, having a peculiar odor like that of new pine sawdust 
and is made by the action of sulphuric acid upon oil of turpentine, 
which is then distilled at about 160° F. 

Therapeutics.— Terebene is a useful stimulating expectorant, in 
the late stages of acute or in chronic bronchitis to liquefy and get rid 
of the mucus which is clogging the bronchial tubes. The drug may 
be given by way of the stomach or by inhalation. A useful mixture 
in the later stages of bronchitis when the mucus is very thick and 
tenacious is one composed of equal parts of terebene, iodide of 
ethyl, and chloroform, placed on a sponge and held some two or 
three inches from the face. It has also been employed in genito- 
urinary inflammations of a subacute or chronic form in place of oil of 
sandalwood or copaiba as a stimulant. In fermentative dyspepsia it 
is of service as an antiseptic. The drug should always be given in 
capsule in the dose of 5 to 10 minims (0.3-0.6), or by dropping it on 
sugar in the same amount. This dose may be repeated every three 
hours. Unfortunately, terebene is very apt to irritate the stomach or 
to produce diarrhea, and it sometimes irritates the kidneys. 

TERPINE HYDRATE. 

Terpine hydrate (Terpini Hydras, U. S.) is prepared by a process, 
unnecessary to explain here, from a mixture of pure oil of turpentine, 
alcohol, and nitric acid. In this manner large colorless crystals, 
nearly odorless and with a faint taste, are formed, and in this form 
the drug appears on the market. Terpine hydrate is soluble in 200 
parts of cold, 34 parts of boiling water, and in 13 parts of alcohol. Of 



512 DRUGS 

ether it requires 140 parts for its solution, and of chloroform 135 
parts. 

Therapeutics.— Terpine hydrate is used 'for the purpose of increas- 
ing secretion from pharyngeal, laryngeal, and bronchial mucous 
membranes, and is a useful remedy in subacute or chronic bronchitis 
to rid the tubes of mucus. The drug has also been satisfactorily 
employed in the treatment of hay fever when given in full doses. 
The remedy, while useful in only a limited number of conditions, 
certainly seems to be very useful in the diseases named. The dose as 
generally given is 2 to 3 grains (0.12-0.2), but it may be given in the 
dose of 15 to 20 grains (1.0-1.3) three times a day in hay fever. Ter- 
pine hydrate may be prescribed in pill, capsule, and in alcoholic solu- 
tion flavored with some of the aromatic waters and with the addition 
of a little syrup. Thus: 

1$ — Terpini hydratis gr. lxxv (5.0) 

Spiritus vini gallici f 3ij (60.0) 

Syrupi lactucarii, 

Syrupi tolutani aa fSiij (90.0).— M. 

S. — 1 to 2 dessertspoonfuls (8.0-16.0) three or four times a day. 

Or we may prescribe— 

1$ — Terpini hydratis gr. xl (2.6) 

Acidi benzoici gr. xl (2.6) 

Codeinse gr. v (0.3). — M. 

Fiant pilulse, No. xx. 

S. — One pill three or four times a day. 

An elixir of terpine hydrate with heroin is now widely sold, and is a 
useful preparation to act as an expectorant and allay excessive cough. 
This preparation is contained in the National Formulary under the 
name of Elixir Terpini Hydratis cvm Heroina. Each dram (4cc) 
of it contains 1 grain (0.06) of terpine hydrate and -^ grain (0.004) of 
heroin; the dose is 1 to 2 drams (4.0-8.0 cc) every three hours. 

The nitric acid test for albumin in the urine is fallacious if the 
terpine hydrate is being taken. 

TERPINOL. 

Terpinol is derived from terpine hydrate by boiling the latter with 
dilute mineral acids. Terpinol is an oily substance with an odor 
resembling that of hyacinths. It is almost insoluble in water, but 
dissolves readily in ether and alcohol. It is used for the same purpose 
as terpine hydrate, in the dose of 8 to 20 grains (0.5-1.3), in capsule or 
pill. This dose may be given twice or thrice a day. The drug may 
irritate the stomach and kidneys when given in overdose. 

THAPSIA. 

Thapsia garganica is an umbelliferous plant of Southeastern 
Europe, employed for the purpose of producing a blister. It is gen- 



THIOSINAMINE 513 

erally used under these circumstances in the form of a plaster. The 
resin, obtained from the bark of the root, is the form in which it 
appears in medicine. When applied continuously it produces great 
irritation, and finally sloughs result. 

THEOCIN. 

Theophyllina, U. S., is a minor alkaloid found in tea leaves. It is 
insoluble in water, somewhat irritant to the stomach, and is a dime- 
thylxanthin in distinction from caffeine or theine, which is trimethyl- 
xanthin. 

Because of its insolubility, acet-theocin-sodium has been made from 
a synthetic theocin, as it is soluble in 25 parts of water and contains 
65 per cent, of theocin. Acids and acid fruits are not to be given 
with acet-theocin-sodium as they will precipitate theocin. 

Physiological Action. — The chief influence of this drug is exercised 
upon the secreting epithelium of the kidney, upon which it acts as a 
stimulant and if the kidney be inflamed as an irritant. It is there- 
fore to be used with caution in acute nephritis if at all. 

Therapeutics.— The best effects of acet-theocin-sodium are produced 
in the relief of cardiac dropsy, in which state it is said to often cause 
profuse diuresis. It does much less good in renal dropsy. As its 
effect on the heart is slightly stimulant it aids diuresis by increasing 
circulatory activity. Unfortunately, the drug loses its effects after it is 
used for four or five days. It should be stopped for several days and 
then given again. The dose is 2 to 3 grains (0.1-0.15), dissolved at 
each administration in pure water and given twice or thrice a day after 
food. 

THIOCOL. 

Thiocol is derived from guaiacol, the chief active .ingredient of 
creosote, and is, technically speaking, potassium guaiacol-sulphonate. 
It is a white fine, crystalline powder, readily soluble in water and 
in diluted alcohol, and possessing a slightly bitter, salty taste. Thiocol 
is used in medicine as a substitute for creosote, and guaiacol in the 
treatment of chronic bronchitis and tuberculosis of the lungs, and is 
given in the dose of 10 to 30 grains (0.6-2.0) three times a day. Its 
advantages are its comparative tastelessness, its ready absorbability, 
and the fact that it does not irritate the stomach. It may be given 
in powder on the tongue or in capsule. 

THIOSINAMINE. 

Thiosinamine is derived from volatile oil of horseradish, or more 

commonly from the volatile oil of mustard-seed, by the addition of 

alcohol and ammonia-water and exposing it to heat. Under these 

conditions crystals of thiosinamine are deposited in prisms which are 

33 



514 DRUGS 

soluble in 2 parts of warm water, and in alcohol or ether. A solution 
of it should not redden litmus paper. 

When given by the mouth the dose is \ to 1 grain (0.03-0.06) three 
times a day. Larger doses may disorder the stomach. If this does not 
occur, as much as 3 grains (0.2) may be used. Thiosinamine is used 
also for the cure of lupus in scars, and keloid, and it has been used with 
asserted success in malignant growths. In a case of keloid the drug in 
10 per cent, solution in absolute alcohol may be injected directly into 
the part affected in the dose of 10 to 20 minims (0.6-1.3) every third 
or fourth day. The part receiving the injection usually becomes con- 
gested and swollen and dark in hue. There is often a great increase 
in the quantity of the urine, and perhaps nausea and vomiting, and 
great pain where the injection is given. In cases of lupus it may be 
injected locally or at a distant spot, and produces a reaction like that 
caused by tuberculin. Before thiosinamine is used it is necessary to 
exclude the possibility of the presence of any other old inflammatory 
focus, particularly if it be tubercular in origin, since the drug may light 
up a partly healed lesion into an active inflammatory process. 

The effect of thiosinamine upon certain abnormal tissues is extra- 
ordinary. When injected subcutaneously, or when given by the 
mouth in some instances, it causes a local reaction in those parts of 
the body in which scar tissue exists or where poorly developed patho- 
logical tissues are present. Because of this reaction the part affected 
undergoes more or less resolution and absorption takes place. After 
a hypodermic injection the effect is produced in a few hours, but 
when given by the mouth the effect is produced more slowly, if at all. 
The duration of the effect of a single dose is about five hours. Because 
of the softening which it causes in sclerotic tissues it has been used 
for the removal of scars, for the dissipation of corneal opacities, and 
for the relief of deafness due to thickening of the drum or fixation of 
the aural bones. 

For some reason thosinamine has not become as popular as its 
action upon some tissues would lead us to expect. A modified form 
of thiosinamine, called Fibrolysin, made by mixing thiosinamine 
with sodium salicylate, possesses the advantage of being soluble in 
water, but this solution has to be freshly made, as it soon under- 
goes oxidation, or it can be put up in sealed vials each of which 
contains one dose of 20 grains (1.3) of fibrolysin, which is equivalent 
to about 3 grains (0.2) of thiosinamine. The best way to use it is 
by intramuscular injection, which is said to be painless. Although 
highly praised by many German clinicans, fibrolysin, like thiosina- 
mine, has never become popular in this country. One of the chief 
objections to its use is that it may cause the breaking down of inflam- 
matory exudates designed by nature to protect the body, as well as 
of harmful exudates. Thus its use may cause the spread of a partly 
healed tuberculous focus. 



THYMOL 515 



THYMOL. 



Thymol, U. S. and B. P., is derived from the oil of thyme and other 
volatile oils, and occurs in large crystals. It is soluble in water 1 
to 1500, but is freely soluble in fats and oils. Thymol is irritant in 
large amount. It is antiseptic and germicidal, and in saturated solu- 
tion in water is the most efficient antiseptic mouth-wash. Thymol 
is an excellent remedy in uncinariasis. Under these conditions it 
should be used in gelatin-coated pill or konseal, and a glass of water 
or milk taken to avoid the burning sensation otherwise produced. 

When thymol is to be given for hookworm, all fatty foods are for- 
bidden, as this drug is soluble in fats, and when dissolved is readily 
absorbed, which is undesirable. The patient is starved for twelve 
hours, then purged with magnesium sulphate, and after this the 
thymol is to be swallowed. Five hours after the thymol is given, a 
second dose of magnesium sulphate is used to sweep out the parasites. 
The dose of thymol must be fairly large, from 5 grains (0.32) for a 
child to 60 grains (4.0) for an adult. If the patient is too feeble to be 
actively purged, a dose of 5 grains every week for several weeks may 
be resorted to. The following table of doses according to age may be 
followed in fairly strong persons : 

Under 5 years up to 5 grains 

5 to 10 years 8 to 15 " 

10 to 15 " 15 to 30 " 

15 to 20 " . 30 to 45 '" 

20 to 60 " . 45 to 60 " 

After 60 years 45 grains 

In the treatment of stomatitis or tenderness of the gums after mer- 
curialization, the following mouth-wash may be used: 

I^— Thymolis gr. v (0.32) 

Sodii boratis gr. xv (1.0) 

Aquae ... fgij (60.0).— M. 

S. — Place a teaspoonful (4.0) of this in f a tumblerful of water and use as a gargle. 

Thymol has been used for dressing ivounds, but is too costly for 
general use. In summer weather it cannot be employed, because of 
its attraction for flies, which make the patient's life miserable. 

The average dose is 2 grains (0.12), in capsule or in wafer, and it is 
better to follow its use by a glass of milk to prevent the drug irri- 
tating the stomach. In typhoid fever as much as 30 grains (2.0) in 
twenty-four hours have been given as an intestinal antiseptic; in this 
disease it is of little value. 

If very large amounts (100 grains [7.0] ) are taken in a day, poisoning 
may result, but this much must be used before danger is present. 

Thymol Iodide. 

Thymolis Iodidum,, U. S. is a compound of iodine and thymol, some- 
times called aristol, but more correctly dithymol diiodide. It is 



516 DRUGS 

obtained by the condensation of two molecules of thymol and the 
introduction of two atoms of iodine into the phenolic groups of the 
thymol; it contains 45 per cent, of iodine, and was introduced into 
medicine for the purpose of acting as a substitute for iodoform. It 
should be kept in amber-colored glass vials to protect it from light. 
Its color varies from that of chocolate to reddish yellow. It is insol- 
uble in water and glycerin; slightly soluble in alcohol at 25° C. (77° 
F.) ; readily soluble in ether, chloroform, collodion, and in fixed and 
volatile oils, leaving a slight residue. It is free from the unpleasant 
odor of iodoform, and it is stated to be less apt to produce poisoning 
by absorption. Much contradictory experience has accumulated 
as to its exact value, but the result of a careful examination of clinical 
reports is that in some respects it is a better drug than iodoform and 
in others not so good. 

TichhofT and Neisser state that when taken internally thymol iodide 
is incapable of causing toxemia, but this can only be true when moder- 
ately large doses are given. Upon cocci and bacilli thymol iodide 
has less power than iodoform. In regard to the power of this drug 
in healing wounds or sores, the decision has been reached that when- 
ever secretion is free it is contraindicated, as the thymol seems to 
increase moisture. On the other hand, in those instances where in 
disease of the skin or mucous membrane an undue dryness is present 
the effect produced is often favorable. Upon lupus little effect is 
produced unless the surface is first curetted. Finely powdered thymol 
iodide has been found of marked value in the treatment of inter- 
stitial keratitis by de Schweinitz and Wallace when dusted into the 
eye each day. In an ointment of J to 1 dram to the ounce of lard 
(2.0-4.0 : 30.0) thymol iodide may be used in psoriasis, but it is not 
so useful as is chrysarobin in this affection. 

THYMUS GLAND. 

The thymus gland has been used quite largely in certain diseases 
on the same principle as that governing the use of the thyroid, namely, 
that this gland possesses the function of internal secretion and will 
therefore benefit certain systemic conditions in persons in whom the 
thymus was atrophied too early in life. Others have used it as a sub- 
stitute for the thyroid, intentionally or by mistake. Its chief use has 
been in the treatment of goiter (not exophthalmic) . It does not pro- 
duce any disagreeable effects as does the thyroid. Parke, Davis & Co. 
prepare thymus gland in tablets and capsules ready for use, and this is 
the best form in which to prescribe it. 

THYROID GLAND. 

Dried thyroid gland (Thyroideum Siccum, U. S. and B. P.) is the 
cleaned, dried, and powdered glands of the sheep, freed from fat. It 



THYROID GLAND 517 

appears as a yellowish amorphous powder, having a slight, peculiar 
odor, and containing the active ingredient of the thyroid gland; par- 
tially soluble in water. One part of the dried gland represents approxi- 
mately 5 parts of the fresh gland. Occasionally it represents as much 
as 10 parts of the fresh gland. 

The thyroid gland is used for the purpose of relieving certain dis- 
turbances of nutrition of which the most characteristic are myxedema 
and cretinism. The results obtained from its use in these states are 
extraordinary, and it is to be regarded as a specific if the condition is 
not too well established. Its use is based upon the fact that in cases 
of myxedema the thyroid gland is usually found atrophied, and upon 
the discovery of Reverdin, Kocher, Schiff, Fuhr, Horsley, Crede, 
Zesas, and others, that extirpation of this gland produces myxedema 
or a train of symptoms practically identical with it. 

It is customary to employ the desiccated thyroid gland ( Thyroidum 
Siccum) in a powdered form, or made into a tablet or placed in a 
capsule, in place of the raw gland itself. The dose of this is 1 grain 
(0.06) three times a day, which dose is gradually increased as the 
patient becomes accustomed to it. Although the remedy when 
first employed is given in the dose of about 1 grain (0.06), it may 
be rapidly increased a grain a day until about 6 grains (0.4) a day 
are reached, when a halt is made and the effect of this dose watched 
for some days. If the patient does not manifest symptoms of over- 
dose, on the one hand, or if he fails to improve on the other, then the 
dose may be still further increased. No more than 15 grains (1.0) of 
the dried gland should be given each day, and this quantity should 
be divided into several doses. 

After marked improvement or apparent cure has been effected by 
the treatment, it is necessary for the patient to continue using 
thyroid extract indefinitely, for if it is discontinued the myxedema 
returns. The remedy may be given in minute daily doses or in full 
doses for several days at the end of every three weeks or a month. 
Though the latter plan is the more disagreeable, it is asserted to 
possess a greater therapeutic and preventive value. 

Thyroid gland has been used very largely in the treatment of cre- 
tinism with success only second to that attained in the therapy of 
myxedema, and with asserted success in dwarfism, excessive obesity, 
psoriasis, and scleroderma. 

The rapid growth of cretins under thyroid gland therapy may lead 
to bending of the bones, and care should be taken that too much 
exercise on the feet is prevented. When used in obesity, an increased 
amount of nitrogenous food should be supplied to prevent loss of 
strength, as this gland causes increased catabolism not only in the 
fatty, but also in the proteid parts of the body. Under its influence 
the body cannot assimilate glucose if it is ingested in full doses, and 
glycosuria develops. In obese diabetics the gland is probably a 
dangerous drug for this reason. In the author's experience its effects 



518 DRUGS 

are inconstant in obesity. It benefits some patients and is useless 
in others. 

Because of the very great effect of this gland upon nutritional 
processes it has been employed in a host of ailments in which there 
has been no prospect of producing good effects. Among these, how- 
ever, some experiments have resulted so favorably that the use of the 
gland has received recognition, although we do not understand exactly 
how it does good. Thus in the dose of from 5 to 20 grains (0.3-1.3) 
three times a day, according to the degree to which it produces its 
effects, it has proved of value in acute mania and melancholia, puer- 
peral and climacteric insanities, and in stuporous states with primary 
dementia. The treatment should be persisted in for at least thirty 
days, according to Mabon and Babcock. Recently the use of full- 
doses of thyroid gland has been strongly recommended for the pre- 
vention and relief of the early symptoms of eclampsia on the ground 
that it relaxes the renal bloodvessels, increases urinary flow, and also 
increases the elimination of urea. 

Thyroid gland given in the dose of 5 grains (0.3) in the early morn- 
ing, followed by quiet and, if possible, by sleep, sometimes relieves 
the vomiting of pregnancy. A dose may also be given at bedtime. 
Given during the last weeks of pregnancy it may be employed to 
induce a flow of milk in women who have had no secretion after pre- 
vious pregnancies. 

It has also been asserted that thyroid therapy is useful in the treat- 
ment of exophthalmic goiter, but this is positively untrue, and it may 
seriously injure such a patient, since in overdose the gland causes 
symptoms like those of exophthalmic goiter. 

Dried thyroid gland, or preparations made from it, will probably 
be displaced by thyrox in, a definite chemical compound isolated by 
Kendall from animal thyroids. It is to dried gland what an alkaloid 
is to a crude drug and contains about 65 per cent, of iodine; fa grain 
equals about 30 grains of desiccated thyroid gland. Thyroxin is a 
stable substance, given to an adult with myxedema in the dose of 
to to -fa grain (0.0015-0.002) a day. This last dose taken continu- 
ously by a normal person will induce symptoms of hyperthyroidism 
after some days. In cretinism it is used in the dose of -g-g--^ to rio" 
grain (0.0002-0.0004). Thyroxin is to be had in powder and in 
tablets containing the above doses. The tablet is to be dissolved in 
a glass of water containing half a dram (2.0) of sodium bicarbonate. 
Its use should be stopped if the pulse rate gets up to 100, and if the 
weight of the patient is decreased with great rapidity, a smaller dose 
should be used. It is to be recalled that its effects do not usually 
appear for several days and when once established may persist for 
several weeks, but in colloid goiter its use often causes a rapid diminu- 
tion in the size of the gland which remains small as long as the remedy 
is employed and it may be after it is discontinued. 

Under the name thyroprotein has been prepared a concentrated 
extract assayed and adjusted so that it contains a standard amount 



TRIKRESOL 519 

of iodine (0.33 per cent.), which is used as a substitute for thyroid 
extract in 2-grain (0.12) tablets made up of thyroprotein and lactose 
in the strength of 1, 2, and 5 per cent., each equalling -fa, -^V and yo 
grain. It is also put in sterile ampoules for hypodermic use equal 
to 5^- gr. One tablet is given once to thrice a day. 

In the B. P. the dried gland ( Thyroideum Siccum) is also official, 
as is the Liquor Thyroidei, dose 5 to 15 minims (0.3-1.0). 

Untoward Effects.— Overdoses of thyroid produce violent headache, 
feeble action of the heart, and sometimes diarrhea and vomiting. 
Should any of these symptoms come on, they are an indication for the 
complete stoppage of the use of the drug for some days, and a return 
to its use must be gradual. These symptoms can be avoided by 
cautious dosing and by keeping the patient in bed for some days 
after the treatment is inaugurated. 

THYROIDECTIN. 

Under this name the dried serum of animals which have been sub- 
jected to thyroidectomy is used for the relief of exophthalmic goiter 
or Graves s disease. The theory is that as a result of removing the 
thyroid gland in the animal a state is produced in which the serum 
lacks the normal content of thyroid secretion, and when this serum 
is given to a patient suffering from Graves's disease it unites with the 
excess of thyroid secretion in the patient's blood and so diminishes 
or antidotes its effect on the body. Under the name of " Antithy- 
roidin" the liquid serum is given in the dose of 10 to 75 minims 
(0.65-5.0) in milk. Under the name of "Rodagen" the dried milk 
of thyrodectomized goats is given in similar cases in the dose of 1 to 
4 drams (4.0-16.0) daily. Thyroidectin is prepared in this country, 
Dose, 5 to 10 grains (0.3-0.6) t. i. d. 

TRICHLORACETIC ACID. 

Acidium Trichloraceticum, U. S., is a compound of chlorine and 
acetic acid, occurring in deliquescent crystals, and used as a rapid, 
active escharotic upon venereal and other warts. A peculiarity in its 
effect is that it produces a dry scab which speedily falls off, leaving a 
healing surface beneath. It is also claimed that its action is not 
followed by secondary inflammation and pain. It may be used by 
applying a crystal to the wart or other growth, and protecting sur- 
rounding parts with collodion, or else it is applied in liquefied form 
by using a glass rod and rubbing it into the part. 

TRIKRESOL. 

Trikresol is a combination of ortho-, meta-, and paracresol, bodies 
allied to creolin and phenol. Trikresol appears in commerce as 
a white liquid, smelling somewhat like creosote, and soluble in water 
in the proportion of about 2\ per cent. It forms a clear solution, 



520 DRUGS 

and does not benumb the skin as does phenol. It is also much less 
irritant and less poisonous than phenol or bichloride of mercury. 

Therapeutics.— Trikresol is used as an antiseptic in surgery in 1 
per cent, solution. In the strength of 1:1000 to 1: 500 it may be 
employed as an antiseptic collyrium in ophthalmic practice, in which 
field it has proved useful. 

TRIONAL. 

Sulphonethylmethanum, U. S., and Methylsulphonal, B. P., or trional, 
is related, both chemically and therapeutically, to sulphonal, and is 
practically identical with that drug in its effects on the general system. 
It occurs in shining, odorless, colorless plates with a very faint, bitter 
taste, and is soluble in 200 parts of water. Trional is used for the 
relief of insomnia of a functional type, and the sleep produced ordi- 
narily ensues in about twenty to thirty minutes after the drug is 
taken, and lasts five to six hours. The dose is 15 to 30 grains (1.0-2.0) . 
Doses larger than 15 to 30 grains should never be given continuously, 
and it is always a good plan after the drug has been given for five or 
six consecutive days to stop its use for two or three days. It is well 
to order for the patient who is taking trional one of the saline purga- 
tives daily, particularly if there is any tendency to constipation. 

Trional is slightly soluble in water and very soluble in alcohol. 
Advantages in its use are lack of disagreeable taste and the absence 
of" symptoms of circulatory depression. The best way to administer 
trional is in hot broth or tea or whisky. It is wise to decrease gradu- 
ally the dose if the drug is taken night after night. Like sulphonal, 
trional is apt to make the patient drowsy the day after its ingestion. 

When trional is taken in full dose for several weeks, -it produces 
alterations in the blood which are manifested by hematoporphyrin- 
uria— a state in which the urine is dark red or almost black. The drug 
should be stopped at once when the urine becomes red and saline 
purgatives must be used freely. There are no characteristic symp- 
toms of trional-poisoning save profound coma. The pupils are not 
contracted as in opium-poisoning. 

TROPACOCAINE. 

Tropacocaine is a vegetable alkaloid derived from Coca Erythroxy- 
lon as is its sister alkaloid cocaine. It is found in larger proportions 
in coca grown in Java than in coca grown in Peru. It is only half as 
toxic as cocaine. In water it forms a neutral solution, and its solutions 
can be sterilized by boiling. Almost its sole use in medicine is for the 
induction of spinal anesthesia when injected into the subarachnoid 
space. For such use it is best obtained in sterile glass ampoules 
containing about 20 minims (1.3) of 25 per cent, solution, that is, 
about 1 grain (0.06) of the drug. This is the dose for a strong, well- 
developed man. For the aged and feeble 10 or 15 minims (0.05-1.0) 
is sufficient. The method is contraindicated in persons with a low 
blood-pressure. (See Procaine.) 



TUBERCULIN 521 

TUBERCULIN. 

Tuberculin is prepared in several ways which vary widely, but the 
product is, to all intents and purposes, the same as to its effects, 
although it may vary as to its strength and applicability. It occurs in 
several forms as follows: 

Old Tuberculin (O. T.) is made from human tubercle bacilli grown 
on bouillon with 5 per cent, of neutralized glycerin. The bouillon 
is boiled until concentrated to one-tenth its volume and then 50 per 
cent, of glycerin is added. It is then filtered to rid it of bacilli. It 
is chiefly used for diagnostic purposes (see below). Its diagnostic 
hypodermic dose is ^ to 1 mg. Its therapeutic dose looo o'to 10 1 00 mg. 

Bouillon Filtrate (B. F.) Tuberculin is made as is Old Tuberculin, 
except that it is not concentrated and not diluted with glycerin except 
to the extent of 5 per cent. The only protection from living bacilli 
being in it is the filter, as there is no boiling. It is not used for diag- 
nosis. Its therapeutic dose is two o to toVo m g- It * s sometimes 
called Denys' Tuberculin. 

Tuberculin T. R. or Tuberculin Residuatum, is made by growing, 
evaporating to dryness in vacuo, and grinding the bacilli. The 
ground residue is then dissolved in salt solution and centrifuged. 
The centrifuged residue is again dried, ground, and dissolved repeat- 
edly until the final addition of salt solution makes a clear fluid. Its 
therapeutic dose is to i or to ^or o" m £- This is the tuberculin most 
used for therapeutic purposes. 

Tuberculin B. E. (Bacillen Emulsion) is prepared by pulverizing 
and suspending in glycerin solution tubercle bacilli. Its therapeutic 
dose is 10 q 00 to T lro m g- for therapeutic purposes. 

It is important to remember that 1 mg. of Old Tuberculin and of 
Bouillon Filtrate is not identical with 1 milligram of Tuberculin 
Residuatum or Bacillen Emulsion. The former do not contain any 
tubercle bacilli solids, they are only solutions in which the bacilli have ' 
grown, whereas in the case of Tuberculin Residuatum and Bacillen 
Emulsion the actual solids, made by grinding of the bacilli, are 
present in solution or suspension; that is, 1 milligram of tubercle 
bacilli solids weighed after drying. They are, therefore, more accur- 
ate preparations. 

Physiological Action.— Although the products of the processes just 
described differ in their physical appearances and in their strength, the 
effects following the injection of any one of them into the human body 
is a difference in degree rather than in kind. While the filtrates have 
been supposed to exercise an antitoxic effect and the emulsions an anti- 
bacterial effect, there is no scientific proof of value to support this 
belief, and it is now well recognized that as the tubercle bacillus does 
not secrete or make a toxin, the word antitoxic, in the ordinary accep- 
tation of that term, cannot be employed. On the contrary, the object 
of employing tuberculin, whatever its form, for curative purposes is 



522 DRUGS 

to stimulate the protective processes of the body. To illustrate this, 
the following experimental result may be cited: If a guinea-pig is 
inoculated by the tubercle bacillus the point of inoculation speedily 
heals, but about two weeks later breaks down and a persistent ulcer 
forms. If, however, the animal has been inoculated on a previous 
occasion, the second spot becomes red within a few hours, soon breaks 
down and ulcerates, and then speedily heals. Furthermore, the 
nearby lymph nodes do not enlarge as after a primary inoculation. 
In other words, the primary inoculation has enabled the animal to 
overcome the second one. 

It is to be remembered that tuberculin in any dose is not in itself 
capable of exercising an influence upon a healthy person, but only 
acts if an individual is rendered hypersensitive by reason of the fact 
that he is tuberculous. In such persons it is supposed that various 
antibodies or lysins are formed which split up tuberculin and so form 
a poison to which the cells of the body react, this change taking place 
not only to the tuberculin injected, but in the tuberculin formed by 
the bacillus which has infected the patient's body. It is to be remem- 
bered, then, that when injected in full dose into a healthy man tuber- 
culin has no action, but when injected into a tuberculous man it has 
a very powerful effect, which varies with the dose and the ability of 
the patient to react. This effect consists in local and general mani- 
festations. At the point of injection there is hyperemia, swelling, 
heat, and soreness. At the area of tuberculous infection there is a 
similar state. If this area is visible it is seen to be red and hyperemia 
If this area is in the lung, rales often develop where before nothing 
but slight dulness on percussion and tubular breathing were present. 
The general effect consists in a train of symptoms closely resembling 
those of epidemic influenza. There is pain in the bones, headache, 
general malaise, and more or less well-marked febrile movement, 
often preceded or accompanied by a chill and sweat. The pulse is 
quickened and the patient may, if the reaction be severe, feel exceed- 
ingly ill and weak for a period varying from a few hours to even as 
long as two weeks or more. 

Therapeutics.— When used for treatment, tuberculin is not employed 
as a direct curative agent, but as one which will stimulate the pro- 
tective processes of the body to overcome the invading microorganism. 
Different methods are employed in its administration. Some give it 
in such large doses that the patient suffers from more or less reaction, 
but the best method is that in which such infinitesimal doses are 
given that there is no reaction in the coarse sense, but only stimulation 
of the protective processes. As the patient improves, larger and larger 
doses may be given to still more stimulate these processes, but the 
greatest care is to be used never to cause reaction. 

Tuberculin is never to be used for treatment or diagnosis if the 
patient is febrile, or so feeble that he cannot react. Acutely ill or far- 
advanced feeble cases are, therefore, not suitable to its use. Rapid 



TUBERCULIN 523 

results are not to be expected. This plan of treatment must often be 
used as long as a year before it may be considered as fairly tried. 
Manifestations that the patient is improving are a diminution of the 
symptoms of his disease and a gain in weight. 

I am strongly of the opinion that tuberculin should be used for treat- 
ment only by those who have had special training in its use. More 
harm than good follows its employment by the general practitioner. 

Cooke, of London, makes this comprehensive statement which I 
heartily endorse : " The system of dosage and the method of increase 
cannot be learned or acquired by reading from a text-book; and, as a 
matter of fact, no book could be written with any degree of accuracy 
on this part of the subject. It is a question of personal experience, 
and that can only be acquired by personal attendance at a properly 
conducted tuberculin dispensary several hours a week over several 
months." 

Administration.— In the treatment of tuberculosis by tuberculin 
it is always given hypodermically and usually into the subcutaneous 
tissues, not the muscles, of the back. It is best to use a specially 
devised tuberculin syringe graduated in hundredths of a cubic centi- 
meter. It must be borne in mind that patients vary greatly in the dose 
which they can take. Each case is a law unto itself, and, in order to 
avoid disagreeable effects, the initial dose should be exceedingly 
small and in the nature of a " feeler." Further, it not infrequently 
happens that if no visible reaction follows the first dose, it develops 
after the next one, so the second dose should not be greater than the 
first, nor should the dose be increased until there is enough evidence 
to justify the belief that this can be safely done. The site of the last 
injection should always be carefully examined to discover if it is 
indurated or tender. If it is, this sign of local reaction warns against 
larger doses until this local irritation ceases to exist. So, too, if there 
is present a febrile movement, even if it be only a few fractions of 
a degree, the dose should be postponed. Reaction to an injection 
usually develops within a few hours of the injection at the latest. If 
fever comes on as late as forty-eight hours, it is probably due to 
another cause. If by an error a reaction has ensued, the treatment 
must stop for a period of at least ten days to two weeks after all signs 
of it have ceased, and, on renewing the treatment, the dose should be 
much smaller than the one that induced the disagreeable symptoms. 
The ordinary rules of strict cleanliness are to be followed as to the 
injection. If they are, there is no danger of local sepsis. 

Dosage.— The dose varies, as already stated, according to which 
tuberculin is to be used for therapeutic purposes. "When tuberculin 
is employed for treatment the initial dose is usually Tolhro m g-> but 
if the patient is not in good condition, less than this, i. e., towoo" m g- 
If this small dose is well borne, the dose may be doubled, but when, 
by the process of doubling, the dose reaches thousandths or hun- 
dredths of a milligram, very great care must be used in making a 



524 DRUGS 

further increase. The smaller doses may be given twice a week; the 
larger ones are usually employed once a week. T. R. and B. E. are 
now placed on the market by the best manufacturing pharmacists, 
in the form of hypodermic tablets, which are the best, as they are 
more convenient, and in small glass vials, hermetically sealed, usually 
containing 1 cc of tuberculin solution, equaling 1 milligram of dry 
tubercle solids. If to yV cc (0.1 cc) of this solution is added 100 
cc of sterile salt solution, 1 cc of this dilution will, of course, equal 
one one-thousandth of a milligram, two" J an d if 1 cc of this dilution 
is diluted by 10 cc of salt solution, each cubic centimeter will equal 
one ten-thousandth of a milligram, towo"J or > to put it differently, 
yV cc (0.1 cc) of the dilution made by adding 100 cc of salt 
solution to one-tenth of the original package will equal T ^ q-q mg. 
The balance of the dilution so made is always thrown away unless 
other patients can receive simultaneous doses, as it decomposes; that 
is, the dilution decomposes if kept for any length of time. 

Diagnosis.— When old tuberculin is used for diagnostic purposes the 
physician uses a dose which is large enough to cause a definite reaction 
if tuberculosis is present. In other words, he expects the injection to 
be followed by a rise of temperature and a certain degree of malaise 
and discomfort if the patient is infected by this particular bacillus. 
This diagnostic dose is, therefore, far larger than that employed for 
the purpose of increasing the patient's resistance. It usually amounts 
to from t^ to 1 milligram (0.0001-0.001), according to the condition 
of the patient. If he is feeble, the smaller dose is the one of choice. 
The reaction, if the patient is tuberculous, develops in about four to 
twelve hours, and lasts from twenty-four hours to several days. If no 
reaction follows the first dose, gradually increasing doses are used, up 
to 5 milligrams or even more. Not only are general symptoms pres- 
ent, but at the site of the injection the parts are reddened and local 
lesions of tuberculosis show inflammatory changes. The test is not to 
be employed in febrile patients, that is, those whose evening tempera- 
ture exceeds 99° F. It is also to be recalled that occasionally those 
who are not tuberculous give a positive reaction if they are old syphili- 
tics. Tuberculous lesions long since healed, and in no way responsible 
for the present ill health, may do likewise. It also fails to cause a 
reaction in a small proportion of tuberculous cases. The test is not, 
therefore, infallible. 

Although those who have studied the reaction following the hypo- 
dermic use of tuberculin tell us that, when properly used, it is not 
dangerous, there is, nevertheless, a feeling among the majority of the 
profession that the reaction may be injurious to the patient. This 
has been the attitude of the author ever since tuberculin was first 
introduced as a diagnostic agent. When a patient presents sufficient 
physical signs or other symptoms to lead the physician to the belief 
that he is probably tuberculous, it is better to treat him as a tubercu- 
lous case, since under these circumstances no harm can be done, and if 



PLATE. II 







Positive Tuberculin Skin Reaction of von Pirquet. (Hamill. 

The middle spot, where there is no redness, shows the effect of 
scarification without tuberculin. 



PLATE III 







Tuberculin Skin Reaction of Moro. (Hamill.) 

Upper figure, moderately severe reaction Lower figure, severe reaction, 
in right-hand ring only lanolin was rubbed in as a control test. 



TUBERCULIN 525 

not tuberculous he is certainly in a fair way to become so, the impaired 
lung being a ready field for the growth of the tubercle bacillus should 
it enter the chest. Do not forget the wise saying, "the use of tuber- 
culin in diagnosis is like looking for a gas leak with a lighted match." 

The ophthalmo-tuberculin test is prepared by dropping into a healthy, 
never into an inflamed, eye a small amount of tuberculin. This is 
now placed on the market in disks or tablets containing the amount 
necessary. This dose is dissolved in five drops of water, which is then 
dropped into the conjunctival sac. Within three to twenty-four hours 
a more or less sharp conjunctivitis develops, ranging from a slight 
inflammation to a purulent condition. If the test is negative and it is 
desired to repeat it, the procedure must take place in the opposite eye, 
because the tissues of the first eye have been sensitized and will give a 
reaction even if no infection by the tubercle bacillus exists elsewhere. 
The test fails, for some unknown reason, in a small proportion of cases 
which are actually tuberculous. 

It should be stated as to the ophthalmo-tuberculin reaction that the 
majority of ophthalmic surgeons are now distinctly opposed to the 
general employment of this test, since there are a number of cases on 
record in which very violent and even disastrous changes have ensued. 

The shin test by the use of tuberculin is in two forms, that of von 
Pirquet and that of Moro. In the von Pirquet test the skin of the arm, 
leg, or abdomen is scarified at three or four spots, as in vaccination. 
Into one of these spots a few drops of pure water and glycerin are 
gently rubbed to act as a control spot. Into the other spots is rubbed 
a few drops of old tuberculin solution (0. T.), which comes put up in 
small glass tubes like those containing glycerinated vaccine lymph. 
In from twelve to thirty-six hours it will be found, if the patient is 
tuberculous, that the spots treated with tuberculin have a reddened 
areola and are crusted as compared to the control spot. This test is so 
frequently positive in seemingly healthy adults that it loses much of 
its value in this class of patients. In young children it is significant. 
If the patient is far advanced in tuberculosis no reaction ensues. 

The Moro test consists in using an ointment composed of 5 cc of 
old tuberculin with 5 grams of anhydrous lanolin. This ointment 
should be freshly prepared or, if kept for any time, should be preserved, 
in a refrigerator. Ten grams of ointment is sufficient for 100 tests. 
A small piece of the ointment about the size of a pea is rubbed into the 
skin of the abdomen or of the chest near the nipple. If the patient is 
tuberculous, a typical reaction develops in the area to which the oint- 
ment has been applied, and consists in the appearance of more or less 
numerous papules which are preceded by an erythematous rash. This 
rash develops in about twelve to twenty-four hours, but sometimes 
not until forty-eight hours have elapsed. It reaches its acme in most 
cases at the end of forty-eight hours. It possesses the great advantage 
of being entirely without danger to the patient, and in the avoidance 
of the nervous perturbation which is sometimes caused by the scratch- 



526 DRUGS 

ing of the skin in the von Pirquet method mentioned above. The 
test loses its positive value in adults, or, to express it otherwise, a 
number of adults who are not actively tuberculous nevertheless pre- 
sent the reaction. 

This ointment is now placed on the market in 2-gram collapsible 
tubes. 

TURPENTINE. 

Much confusion often exists in students' minds as to the difference 
between oil of turpentine (Oleum Terebinthince, U. S. and B. P.) and 
spirit of turpentine, both of which are the same substance under a 
different name. This oil is not, however, the same thing as "tur- 
pentine," for the oil is distilled from turpentine. The distilled oil 
is a thin, clear fluid having a peculiar odor and taste, and is irritant 
to the skin and mucous membranes. It is exceedingly inflammable, 
should never be placed near a light, and if added to any strong mineral 
acid takes fire. 

When turpentine is spoken of in this book as a therapeutic agent, 
the doubly distilled oil of turpentine (Oleum Terebinthince Rectificatum, 
U. S. and B. P.) is what is meant unless the contrary is stated. 

Physiological Action.— Turpentine when taken internally produces a 
sense of warmth in the stomach, a quickened pulse, a warm skin, 
and slightly accelerated breathing. In overdose it may cause intoxi- 
cation. Upon the circulation it produces a very slight rise of arterial 
pressure, increased pulse-rate, and increased heart-force. On the 
nervous system the drug, in large amounts, causes loss of sensation 
before it affects voluntary motion. 

The drug is eliminated by the kidneys and lungs, and gives the 
odor of violets to the urine. 

Poisonous doses causes strangury, bloody urine, renal inflamma- 
tion, and cyanosis, with dilated pupils and gastro-enteritis. 

In persons with an idiosyncrasy to this drug, erythematous, papular 
or vesicular eruptions may follow its external or internal use. 

Therapeutics.— External Use.— Turpentine is used as a local 
application for the purpose of producing counterirritation over any 
area where deep-seated inflammation exists. Under these circum- 
stances it is almost always used in the form of a stupe, made as fol- 
lows : Place a tin cup containing the turpentine in a vessel containing 
hot water, so that the turpentine may be warmed without coming near 
a flame. Dip a piece of flannel into very hot water and wring it out 
in a twisted towel, and when it is so dry that no water drips from it, 
dip it into the hot turpentine and wring it out again to free it from 
any excess of the drug. The cloth, while hot, should be applied and 
allowed to remain until discomfort ensues, when it should be with- 
drawn, as it will blister the skin if left on too long. Children and 
adults suffering from bronchitis may be rubbed on the chest with tur- 



TURPENTINE 527 

pentine with much relief, but it should be diluted with sweet oil, half 
and half, or even two-thirds of oil, particularly if the patient is a child. 

Internal Use.— Turpentine is used internally as a stimulant of 
a diffusible type in the course of the exhausting fevers, particularly 
if flatulence exists or if ulceration of the bowels is present. In typhoid 
fever turpentine stupes, turpentine enemata, and the administration 
of the drug by the mouth are the best ways to overcome tympanites. 
At the end of the second week, when the tongue is red, dry, cracked, 
and brown, the teeth covered with sordes, and tympany is well marked 
"turpentine may be used in emulsion in the dose of 5 to 10 minims 
(0.3-0.6) three times a day with advantage. Again, in convalescence 
from typhoid fever, when diarrhea is persistent and due to an unhealed 
state of Peyer's patches, turpentine is the remedy par excellence. 

In intestinal and other passive hemorrhages, such as Menorrhagia 
or hematuria, the drug is often of service. Why this is so is not 
known. 

For the removal of a tape-worm, turpentine is given in the dose of 
J to 1 ounce (16.0-30.0), mixed with an equal amount of castor oil. 
This treatment is a somewhat dangerous practice, but is efficient. 
In chronic and well-advanced kidney disease large doses of powerful 
diuretics are often required to stimulate the kidneys sufficiently to 
increase urinary flow, and turpentine may be used under these cir- 
cumstances; but it is contraindicated if any acute irritation is 
present, as it may under these conditions produce suppression. 

Turpentine is contraindicated in the presence of any acute inflam- 
mation of the g astro-intestinal tract and in acute nephritis. 

In lumbago the dose of 2 minims (0.12) is said to be very useful, 
and many have found the vapor of turpentine of value in bronchitis of 
a subacute or chronic type when inhaled from boiling water. (See 
Inhalations, Part III.) In gleet it is given by the mouth to stimulate 
the genito-urinary tract. Turpentine has been found of value in the 
treatment of purpura hemorrhagica. 

Turpentine applied with a brush to the part affected is of service 
in ringworm. 

The ointment of turpentine is used as a counterirritant and stimu- 
lant to the part to which it is applied. 

A mixture of turpentine and soapsuds is efficient in destroying 
bedbugs. 

Administration. —Turpentine may be given for the relief of flatu- 
lence by placing 5 minims (0.3) on a piece of sugar, or in emulsion 
(Emubum Olei Terebinthina, U. S.) dose J to 2 fluidrams (2.0-8.0). 

A more agreeable preparation, not to be used in typhoid fever, is 
that recommended by Bartholow, as follows: 

R— Olei terebinthinse f 5j (4.0) 

Olei amygdalse expressi f §ss (16.0) 

Tincturse opii f3ij (8.0) 

Mucilaginis acaciae f 5v (20.0) 

Aquae laurocerasi f5ss (16.0). — M. 

S. — A teaspoonful (4.0) every four hours for tympanites. 



528 DRUGS 

When used as an enema the following is useful: 

3 — Olei terbinthinse f 5j (30.0) 

Olei olivse fSiss (45.0) 

Camphorse gr. xx (1.3) 

Mucilaginis acacia? fBss (16.0) 

Aquae fgx (300.0).— M. 

S. — To be injected as an enema for the relief of tympanites and to aid in the removal 
of hardened feces. Stir thoroughly before using. 

The author most commonly employs turpentine in enema by adding 
it to milk of asafcetida, 1 to 2 drams (4.0-8.0) to 6 ounces (180.0). 

The liniment of turpentine (Linimentum Terebinthinoe, U. S. and 
B. P.) is largely used as a stimulating application to sprains and 
enlarged joints. 

The following preparation is also official in the B. P.: Linimentum 
Terebinthinoe Aceticum. 

UROTROPIN. 

(See Hexamethylenamine.) 

UVA URSI. 

Uva Ursi, U. S., bearberry, is the leaves of Arctostaphylos Uva 
ursi, a widely distributed evergreen shrub. The drug is known in 
the B. P. as Uvae ursi folia. Its active principle is arbutin, some- 
times called ursin. 

Therapeutics.— Uva ursi is employed in medicine as a weak, astrin- 
gent diuretic, possessing alterative power over the genito-urinary 
apparatus. It is used in pyelitis, cystitis, and in chronic gonorrhea 
or gleet. When taken in overdose it escapes from the body as 
hydrochinone, making the urine dark-colored or black on exposure 
to the air. 

Administration.— Arbutin itself is often used in the dose of 3 to 5 
grains (0.2-0.3). The dose of the extract (Extractum Uvce Ursi, is 
1 to 4 grains (0.06-0.25), of the fluidextract (Fluidextractum Uva> Ursi, 
U. S.) is 2 to 4 drams (8.0-16.0) three times a day. An infusion 
(Infusum Uvae Ursi) is official in the B. P., dose 1 to 2 ounces (30.0- 
60.0). 

VALERIAN. 

Valerian (Valeriana, U. S.) is the rhizome and rootlet of Valeriana 
officinalis, sl plant of Europe, but cultivated in America. It is official 
in the B. P. as Valerianae rhizoma. Its active principle is apparently 
a volatile oil {Oleum Valerianae) It also contains valerianic acid. 

Physiological Action.— Valerian is a very feeble sedative to the 
nervous system, tending to produce nervous rest. In male cats it 
causes sexual excitement to a great degree, probably from its odor. 
When very large doses are given to man, it causes a sense of warmth 
in the stomach, a slightly quickened pulse, and sometimes nausea and 
vomiting. Still larger amounts produce purging and mental hebetude. 



VERATRINA 529 

Therapeutics.— Valerian is used alone or in combination with other 
drugs to quiet nervous females and to relieve nervousness and insomnia. 

Langdon Brown asserts that full doses are useful in some cases of 
diabetes insipidus associated with marked nervousness. In hysteria 
it is often very serviceable, and combined with morphine it has been 
much used in the treatment of delirium tremens. In the latter case it 
is probably too feeble to do much good. 

Administration.— The ammoniated tincture (Tinctura Valeriana? 
Ammoniata, U..S. and B. P.), is given in the dose of 1 to 3 drams 
(4.0-12.0), | to 1 fluidram (2.0-4.0), B. P. These are the best 
preparations for ordinary use. The infusion, which is not official, 
is given in the dose of a wineglassful, while that of the simple tincture 
(Tinctura Valeriana?, U. S.) is 1 to 3 drams (4.0-12.0). The dose 
of the oil (Oleum Valeriana?) is 2 to 4 minims (0.12-0.25). 

VALERIANIC ACID. 

Acidum Valerianicum is an oily, colorless liquid of a strong odor 
and burning taste, but is not employed in medicine except in the form 
of its salts, such as the valerianate of zinc, iron, quinine, or ammo- 
nium, all of which are employed, partly for their sedative effects and 
partly for their influence as tonics. 

The dose of Zinci Valeras is \ to 3 grains (0.03-0.2), that of Quinina? 
Valeras 1 to 3 grains (0.06-0.2), of Ferri Valeras 2 to 10 grains (0.12- 
0.6), and of Ammonii Valeras 2 to 10 grains (0.12-0.6). Under the 
name of "the pill of the three valerianates" Goodell recommended 
the following in nervousness and hysteria: 

R — Quininse valeratis, 

Ferri valeratis, 

Ammonii valeratis aa 9j (1.3). — M. 

Fiant pilulae, No. xx. 

S. — One or two pills three times a day. 

VERATRINA. 

• 
Veratrina, U. S. and B. P., is an alkaloid derived from the seeds of 
Asagrcea officinalis, and occurs in a grayish powder, which if it enters 
the nostrils produces violent sneezing which continues for hours. 

Physiological Action.— Nervous System.— Vera trine has little effect 
on the cerebrum, but it excites the spinal cord and the voluntary mus- 
cles, thereby giving rise to tetanic or tonic convulsions, which are 
never clonic or epileptoid. The dominant action of the drug is 
paralytic, and the nervous symptoms just named soon give place to 
paralysis. The muscles lose their contractile power and the nervous 
centers are depressed. 

Circulation.— In poisonous dose the heart is slowed by the drug, 
greatly weakened, and finally stopped in diastole. After death the 
34 



530 DRUGS 

heart is found to be soft and flabby. In smaller doses it at first slows 
the pulse by stimulating the peripheral inhibitory nerves and the 
centers in the medulla, but later these parts are paralyzed. It first 
stimulates the vasomotor center, then paralyzes it. 

Respiration.— The drug kills by failure of respiration, due to 
paralysis of the respiratory centers. 

Temperature.— Veratrine always causes a decrease in bodily heat. 

Poisoning.— The symptoms of poisoning in man are collapse, a 
pale, cold, wet skin, pinched features, and a rapid, thready pulse, 
accompanied by violent vomiting and muscular tremors. Tetanic 
convulsions may come on and resemble those of strychnine in that 
they arise from the slightest touch or draught of air; after death the 
muscles will be found to have lost their irritability. 

Therapeutics.— Veratrine is never used internally. It is employed 
chiefly in the form of an ointment rubbed into the skin over parts 
affected by muscular rheumatism and rheumatic joints and over neu- 
ralgic nerves. It should be used most carefully, as absorption of the 
drug may take place in sufficient quantity to poison the patient. 



VERATRUM VIRIDE. 

Veratrum Viride, U. S., Indian poke, poke root, or swamp hellebore, 
is an American plant largely used for the purpose of depressing the 
circulation and nervous system. Until recently it was official in the 
B. P. under the name of Veratri viridis rhizoma. 

It probably contains a number of principles, but at present our 
knowledge of the chemical constitution and physiological action of 
veratrum viride is in a state of chaos, because some of the European 
pharmacologists seem to confuse it with veratrum sabadilla, which 
contains veratrine as its active principle, whereas veratrum viride 
depends upon other ingredients for its effects. Confusion also exists 
as to the character of its active constituents. When H. C. Wood 
studied the drug, in 1874, he considered that viridin and veratroidine 
were .its two chief principles. Viridin was probably an impure jer- 
vine, and veratroidine is of uncertain constitution. Salzberger has 
isolated an alkaloid which he calls protoveratrine which is exceed- 
ingly poisonous. 

The Committee on Alkaloidal Assays of the American Pharmaceu- 
tical Association state that the constituents of veratrum are as follows : 
Protoveratrine, which is the most powerful and toxic; jervine, which 
is weak, although present in an amount about three times as great as 
protoveratrine; and rubijervine, which is so small in quantity and is 
so feeble in effect as to be almost negligible. Veratroidine, at one 
time thought to be an active principle, is now considered a mixture 
of amorphous bases. 



VERONAL 531 

The same contradictions exist as to its physiological properties 
because of the confusion in the names of its principles, and because 
different pharmacologists have reported diametrically opposed results. 
Thus, the elder Wood taught that veratrum viride is a powerful cardio- 
vascular depressant, whereas the younger AYood reaches conclusions 
directly opposed to those of his father. The studies of the latter are, 
however, more nearly in accord with those of Houghton, and they all 
agree in asserting that veratrum viride greatly slows the pulse, prob- 
ably by stimulation of the vagi. The primary fall of arterial pressure 
may be due to this slowing of the pulse, and not to any depressant 
effect on the heart or vasomotor system, but the dominant effect of 
full doses is a fall of blood-pressure due to depression of the vasomotor 
center. On the other hand, Pitcher and Sollman state there is no 
depression of the vasomotor system, but that the fall of pressure is due 
to the great slowing of the heart induced by stimulation of the vagus. 
Collins has recently shown that in man the drug decreases both sys- 
tolic and diastolic blood-pressure and causes a slowing of the pulse. 

Therapeutics.— Although pharmacologists are so divergent in their 
views as to the effects of veratrum viride, physicians of wide experience 
consider it of peculiar value in a number of states. Thus, many 
practitioners consider veratrum by far the best remedy in puerperal 
eclampsia. If given in this condition, the dose must be large, as 
much as 20 to 30 minims (1.3-2.0) of the fluidextract hypodermically, 
and followed by 5-minim doses until the pulse is reduced to the normal 
rate. These heroic doses are said to be absolutely necessary and not 
to cause any evil effects. Its use is indicated only in cases with high 
arterial tension, a bounding pulse, and suffused face. Under the 
name of Veratrone an excellent preparation of veratrum viride is used 
in eclampsia in the dose of 10 to 15 minims (0.6-1.0) by hypodermic 
injection. It is also of value in excessive cardiac hypertrophy and in 
the irritable heart of strong, healthy men. In aneurism, where the 
circulatory disturbance is great and the arterial pressure high, the 
drug may be used, with great care, to decrease the pressure and pre- 
vent rupture of the diseased vessel. 

Contraindications.— Veratrum viride is contraindicated in all con- 
ditions of depression or exhaustion, and if vomiting is feared. 

Administration.— A good preparation to employ is the tincture 
(Tinctura Veratri viridis, U. S.), dose 5 to 20 minims (0.3-1.3). 
The fluidextract {Fluidextractum Veratri viridis, U. S.) is usually 
given in the nose of 1 to 3 minims (0.06-0.2). Under the name 
of Norwood's tincture a saturated tincture was at one time largely 
sold. It is not official, and ought never be used for this reason. 

VERONAL. 

(See Barbital.) 



532 DRUGS 



VIENNA PASTE. 

Potassa cum calce is a milder and more manageable escharotic 
than is caustic potash, and is used for the same purposes. (See Potas- 
sium Hydroxide.) 

VITAMINES. 

Vitamines are substances the exact chemical nature of which is 
not understood. They are generally divided into two chief classes, 
namely, the fat-soluble vit amine and the water-soluble vitamines. The 
vitamines are absolutely essential to man and animals for the purpose 
of maintaining nutrition, but how they act is undetermined. Prob- 
ably rather by catalysis than by actual nutritional effect, for the 
amount taken daily in foodstuffs is very minute. When an animal or 
man takes food lacking in vitamine content extraordinary nutritional 
changes ensue. When human beings are partly starved of so-called 
fat-vitamine, rickets and dental caries may be a direct result. On 
the other hand deprivation of water-soluble vitamines seems to be the 
cause of beriberi or multiple neuritis, under development, and scurvy. 
When the early symptoms of vitamine starvation are present it often 
happens that a single dose will in a short time make the most mar- 
velous change for the better. When any of the conditions first named 
are present foodstuffs containing a high vitamine content like toma- 
toes and other fresh vegetables and unmilled rice should be fed. In 
many children with general evidences of malnutrition and general 
debility the possibility of vitamine starvation is to be recalled. So 
too, in prolonged lactation producing debility and after long illnesses 
they may prove to be valuable agencies in convalescence. 

When the physician fails to get results from proper foodstuffs or 
when these foodstuffs cannot be taken the abstracted vitamines may 
be employed. The fat-soluble and water-soluble vitamines can be 
obtained on the market in capsules under the name of "Metagen," 
each capsule containing five grains, which should be given to an adult 
three or four times a day. The contents of half a capsule may be 
given to a child in its food, but the food must not be hot as heat 
destroys the vitamine. 



WARBURG'S TINCTURE. 

Warburg's tincture is a complex liquid formed by the mixing 
together of no less than thirteen ingredients. Its inventor, Dr. War- 
burg, held its composition as a secret for a time, but finally made it 
public. Since he published the original formula it has been consid- 
erably altered, and some of the preparations now sold as Warburg's 
tincture probably contain none of the original ingredients. Further 



ZINC ACETATE 533 

than this, some of these ingredients are now not obtainable. It should 
be made as follows, if possible : 

Aqueous extract of aloes 28 gra 

Rhubarb 448 

Angelica-seed 448 

Elecampane 224 

Saffron 224 

Fennel 224 

Gentian 112 

Zedoary-root 112 

Cubeb 112 

Myrrh 112 

White agaric 112 

Camphor 112 

Sulphate of quinine 1280 

Dilute alcohol enough to make 8 pints. 

The coarse vegetable portions of this list are to be ground into a 
coarse powder, and the myrrh and camphor, which have been pre- 
viously pulverized, added to them. The entire mass, less the quinine, 
is then digested for twelve hours in a well-covered vessel on a water- 
bath, the alcohol being prevented from evaporating as much as 
possible. The liquid is now to be strained under pressure and the 
sulphate of quinine added and dissolved. 

Therapeutics.— Warburg's tincture, next to pilocarpine, is the most 
powerful sweat-producer that we have, and possesses in addition 
remarkable antimalarial power. Its advantages rest in its favorable 
action where congestions accompany the malarial paroxysm. 

Administration.— To be of value Warburg's tincture should be 
given according to the following rules: The bowels of the patient 
should be first opened thoroughly by a saline purge, and \ ounce 
(16.0) of the tincture should be given in one dose undiluted, no other 
drink being taken. After the lapse of two or three hours a second \ 
ounce (16.0) is given in the same way, and very shortly a profuse 
sweat appears, which often marks the crisis of the disease, and 
recovery soon takes place. 

ZINC ACETATE 

Zinci Acetas, U. S. and B. P., occurs in the form of white mica- 
ceous crystals, which are efflorescent and quite soluble in water. It 
acts as a decided astringent to the skin and mucous membranes, but 
is less astringent than the sulphate of zinc. It is used as a collyrium 
in eye diseases, such as conjunctivitis, in the strength of 1 to 2 grains 
(0.06-0.12) to the ounce (30.0). In gonorrhea it is often employed 
instead of the acetate of lead in injections of the strength of 1 to 20 
grains (0.06-1.3) to the ounce (30.0) of rose-water. 

The treatment of poisoning by acetate of zinc is that adapted to 
gastro-enteritis. (See Gastro-enteritis, Part IV.) 

Chronic poisoning by zinc is very rare; the symptoms consist in 
muscular palsies, pleuritis, and cachexia. 



534 DRUGS 

ZINC CARBONATE. 

Precipitated carbonate of zinc (Zinci Carbonas Prcecipitatus, U. S.; 
Zinci Carbonas, B. P.) is used as a protective, rather astringent 
powder over surfaces affected by iveeping eczema or other skin lesions 
accompanied by similar moist discharges. It may be employed to 
fulfil all the indications commonly treated by the oxide of zinc. It 
is very largely used, not as the precipitated carbonate, but as the 
impure or native carbonate, under the name of calamine. 

The following prescription is useful for moist eczema: 

3— Calaminse 3j (4.0). 

Ungenti zinci oxidi 3vij (28.0). — M. 

Sig. — Apply to the eczematous spot. 

In cases of infantile intertrigo, or redness of the buttocks and geni- 
tals, from maceration, due to irritating feces, in infants suffering from 
diarrhea, or where the urine is irritating, the following lotion is useful: 

1$ — Pulv. calaminae, 

Pulv. zinci oxidi aa 3ij (8.0). 

Glycerini 3iv (16.0). 

Alcoholis f5ij (60.0). 

Aquae . q. s. ad Oj (480 cc.) — M. 

S. — Apply with a mop after each removal of the diaper and allow to dry. 

ZINC CHLORIDE. 

Chloride of zinc (Zinci Chloridum, U. S. and B. P.) is a white, 
crystalline, deliquescent powder of caustic taste and acid reaction, 
possessing considerable disinfectant power. It has been used as an 
eye-wash in the strength of 1 to 2 grains to the ounce (0.06-0.12 : 
30.0), but is rarely so employed at present. The same solution may 
be used as an injection in the second stage of gonorrhea. Small 
cutaneous cancers, particularly if near bloodvessels, may be advan- 
tageously treated by the following salve, which is efficacious and 
mummifies the tissues so that hemorrhage is prevented: 

I^— Zinci chloridi 3j (4.0) 

Pulv. amyli 3hj (12.0) 

Cocainae hydrochloridi gr. xxx (2.0) 

Aquse destillat 3ij (8.0).— M. 

S. — Apply as a paste. ♦ 

Under the name of Liquir Zinci Chloridi, U. S. and B. P., is pre- 
pared a solution of the salt for disinfecting purposes of the strength 
of about 50 per cent. 

ZINC OXIDE. 

Commercial oxide of zinc (Zinci Oxidum Venale) is not used 
in medicine, but in the purified form is largely employed as Zinci 
Oxidum, U. S. and B. P., which is insoluble in water. In the form 
of the oxide-of-zinc ointment (Unguentum Zinci Oxidi, U. S. and B. P.) 



ZINC OXIDE 535 

this drug affords one of the most generally used applications in the 
treatment of skin diseases, burns, and sores. 

In all states where the surface of the skin is dry it is contraindi- 
cated, but where the eruption is moist it is useful. In the treatment 
of the chloasma of pregnancy the following prescription is of service: 

1$ — Zinci oxidi gr. iij (0.2) 

Hydrargyri ammoniati gr. j (0.06) 

Olei theobromse 3iiss (10.0) 

Olei ricini 3iiss (10.0) 

Essenciae rosse gtt. x (0.6). — M. 

S. — Apply to the face night and morning. 

In eczemas with many vesicles— 

1$ — Pulveris camphorse 5ss (2.0) 

Pulveris zinci oxidi 5hj (12.0) 

Glycerini gtt. xl (2.6) 

Adipis benzoinati Sj (30.0). — M. 

S. — Apply to the part without other treatment or precede it by powdered bismuth. 

Unna's dressing (composed of gelatin 4 parts, water 10 parts, 
glycerin 10 parts, and zinc oxide 4 parts) is a useful application for 
ulcers and eczematous patches on the legs or arms. It is particularly 
useful for leg ulcers. The gelatin and cold water are put in a basin 
over a fire and a solution made; then the glycerin is added, and then 
the oxide of zinc is slowly added, with constant stirring. After the 
mixture is complete it is poured into a can and allowed to cool, when it 
is ready for use. This application decreases swelling and is soothing 
and supporting. It is applied as follows: The part affected is well 
washed with water and soap, and then with alcohol. The paint 
having been warmed and melted, a large three-inch paint-brush is 
used to apply a coating to the limb all around the ulcer, and over this 
a single layer of gauze is applied. The gauze bandage should be two 
inches wide. The bandage must be laid on evenly and the ulcer 
covered by a pad of absorbent cotton. After one layer is applied it is 
cut and another coat of paint applied over it. Then another layer 
of gauze and another of paint are used, until several layers are in place. 
It is best to begin at the toes and work up toward the knee. All parts 
should be equally well covered. Finally the entire dressing is covered 
by a cotton roller bandage, which is removed in twenty-four hours, 
leaving what looks like a white rubber dressing on the limb. If the 
liquid from the ulcer oozes through the dressing profusely, a window 
is to be cut over the ulcer, and it can be locally treated by astringents 
or other measures. The patient should keep the limb elevated for a 
day or two, but can then walk with far more comfort than if a rubber 
supporting bandage is used. 

In powdered form zinc oxide is useful in the treatment of intertrigo 
and for conjunctivitis. Mixed with bismuth subnitrate and pepsin, it 
is largely used by some practitioners in the treatment of the summer 
diarrhea of infants or adults. 



536 DRUGS 

In the night-sweats of debility or of phthisis oxide of zinc in the 
following formula has been highly recommended, but the prescription 
probably depends largely for its action on the second ingredient : 

1$ — Zinci oxidi gr. xxx (2.0) 

Extracti belladonnae foliorum gr. iij (0.2). — M. 

Fiant pilulse, No. x. 

S. — One at night before going to bed. 

Bartholow recommended the oxide of zinc for asthma and whooping- 
cough, given to an adult in the manner just indicated. 

ZINC SULPHATE. 

Zinci Sulphas, U. S. and B. P., is a white, somewhat efflorescent 
salt, of a sharp, acid taste, and soluble in water. In large amounts 
it acts as an irritant, and is employed as an irritant peripheral emetic 
in the dose of 10 to 30 grains (0.6-2.0). It is not so severe as sul- 
phate of copper in its emetic and poisonous properties, and may be 
repeated if the first dose does not produce vomiting. In weak solu- 
tions it may be used as an astringent application by injection in 
gonorrhea and other affections of the urethral mucous membrane. In 
2-grain (0.12) pills it is sometimes given in serous diarrheas, particu- 
larly if it be combined with opium or minute doses of podophyllin -^ 
grain (0.001) as a dose. In conjunctivitis and other eye affections 
the drug is used in the form of a wash. (See Conjunctivitis.) 



PART III. 

REMEDIAL MEASURES OTHER THAN DRUGS, 
FOODS FOR THE SICK. 



ACUPUNCTURE. 

Acupunctuke is a term applied to the deep insertion of a small 
pointed instrument into the tissues of any part of the body for 
the purpose of relieving pain, swelling, or dropsies. When used in 
painful affections it accomplishes its best results in lumbago and 
sciatica, particularly in the former. When treating lumbago in this 
manner the writer places two darning-needles in boiling water to 
render them aseptic, inserts them at right angles to the skin to 
the depth of one to one and a half inches, and allows them to remain 
in place for several minutes. They are then slowly withdrawn, 
care being taken to prevent their breaking. Often after this treat- 
ment the patient can at once move more freely, to his great delight. 
Ringer, with his usual clear clinical insight, has noted that this 
procedure is more successful in those who have bilateral pain than 
in those who have unilateral pain, and the writer has found this 
invariably true. 

In sciatica acupuncture is less successful than in lumbago, but 
sometimes gives relief. The needle should be inserted until it 
reaches the nerve, and, if possible, pierces its sheath, and it must be 
absolutely aseptic. Sometimes the best results follow from insert- 
ing the needle immediately below where the nerve finds exit from 
the pelvis. In other cases it is asserted that the insertion of a 
needle on the sound side over a spot corresponding to that which 
is painful may be beneficial. Acupuncture is useless in acute rheu- 
matism and for the lumbar pain accompaning fevers. 

Sometimes a rhigolene spray may be used to freeze the skin over 
the parts with advantage in lumbago or sciatica. 

Acupuncture is occasionally resorted to for the relief of dropsy, 
but it is not commonly employed. When the skin of the limbs becomes 
so tense with an effusion as to endanger its life, the tension should be 
relieved by incisions, not punctures; but saline purges are better for 
the removal of dropsy, if they can be used. Punctures rapidly close 
and cause local indurations, while incisions remain open and permit 

(537) 



538 REMEDIAL MEASURES OTHER THAN DRUGS 

free drainage. Immediately after the incisions are made the parts 
are to be dressed with cotton previously saturated with boric-acid 
solution and dried, or with absorbent cotton sterilized by baking in 
an oven. It is hardly necessary to point out that the incisions must 
be made with antiseptic precautions. (See Antiseptics and Dropsy.) 

ANTISEPTICS. 

The term "antiseptic," as generally used, does not necessarily 
imply the power to destroy pathogenic germs. Any substance 
which inhibits the growth of microorganisms, which destroys or 
renders innocuous the poisonous products of their action upon the 
tissues of the body, or which retards or prevents the absorption of 
such products, is properly termed antiseptic. 

Bichloride of mercury is efficacious as a germicide in a watery 
solution of 1 : 50,000. Where albumin is present the bichloride is 
decomposed and rendered inert. The same change is observed 
when solutions are allowed to stand for some length of time, even 
when distilled water is used as a solvent. By the addition of either 
sodium chloride or a weak acid such decomposition is prevented. 
From this it follows that under ordinary circumstances solutions 
of bichloride should be freshly prepared, or, if it is desirable to keep 
them for a long time, a sufficient amount of sodium chloride should 
be added to prevent precipitation of the sublimate. Koch advised 
that as much salt should be added as would equal the weight of the 
sublimate. Other observers, however, have advised ten times this 
weight of sodium chloride. 

Since bichloride solutions, when used in wounds or in cavities of 
the body, are brought in contact with blood serum or other albumin- 
bearing tissues, care must be taken that the antiseptic powers of the 
mercury lotion are not destroyed by the neutralization of its active 
principle. The power of the solution may be preserved by using it in 
such excess that the chemical change has practically no effect,orby 
combining with it, as stated above, an acid or salt which will not in 
itself be unduly irritating to raw surfaces. This end is accomplished 
by tartaric acid. In making up a solution, 1 part of bichloride and 
5 parts of tartaric acid are added to as much water as is needed. 
Thus, in making up a solution of 1 : 1000 for surgical purposes, the 
following prescription may be employed. 

1$ — Hydrargyri chloridi corrosivi . . . . . gr. xv (1.0) 

Acidi tartarici gr. xv vel 3J (4.0) 

Aquse destillatae Oij (960 cc). — M. 

In the treatment of infected wounds bichloride solutions are used 
in the strengths of 1 : 500, 1 :1000, 1 : 2000, and 1 : 4000. For the 
irrigation of large cavities solutions of a strength greater than 1 : 10,000 
should rarely be employed; and even these dilute lotions have, when 
used in the peritoneal cavity, caused toxic symptoms. As tissues 



ANTISEPTICS 539 

are devitalized by antiseptics the latter should not be applied to 
clean raw surfaces. Solutions of 1 : 500 or 1 : 1000 are used in cleansing 
the surface of the body. 

The ordinary method of preparing the surface of the body for 
operation is as follows: The part is first thoroughly scrubbed witn 
green soap and warm water, is shaved, and is again w T ashed. It is 
then cleaned with alcohol 70 per cent., after which a scrubbing with 
bichloride solution of 1 : 1000 should follow. If no surgical inter- 
ference is immediately indicated, the whole operative region should 
be enveloped in sterile gauze, and kept thus protected until the 
surgeon is prepared to operate. The moment the skin is incised 
normal saline solution should be used. The dressings, unless some 
peculiar form is used, may consist of sterile gauze, or of boiled, 
bleached, and sun-dried gauze, soaked in a 1 : 500 bichloride solution 
and subsequently washed and wrung out in a 1 : 4000 dilution of the 
same antiseptic. 

Iodine has become popular for skin disinfection. Not less than 
a 4 per cent, solution of iodine in rectified spirit is employed. An 
immediate preliminary washing with soap and water is undesirable, 
since because of the swelling of the epithelial cells from this process 
the iodine does not deeply penetrate. Preliminary cleansing the 
night before is, however, not open to this objection. The operative 
area is painted with the iodine solution after anesthesia is well started 
and again before operation. (See Picric Acid.) In patients with 
extremely delicate skins the iodine may be removed immediately 
after application by means of an alcohol compress or a 2 per cent, 
solution of carbolic acid. The results from this disinfection are 
quite equal to those obtained by the more elaborate procedure 
described above. The iodine is simpler in its application, cheaper, 
and is open only to the objection that it occasionally irritates a 
delicate skin. This may be avoided, as a rule, by using freshly 
made preparations. As a direct application to infected wounds, 
tincture of iodine in full strength has given better results than has 
any other chemical. The requisite for complete cleansing is that 
the iodine must penetrate to every recess of the wound. Even a 
dirty, greasy skin can apparently be disinfected by one painting of 
the tincture. The addition of benzine seems to lessen its irritating 
qualities. 

Of waning popularity among the antiseptic preparations is phenol 
and its solutions. The particular value of this drug lies in the fact 
that its potency is equally developed in both albuminous and non- 
albuminous solutions. Like the mercury salts, its disadvantage 
lies in its toxic properties. It is usually used in solutions of 1 : 20 
and 1:40. The phenol of commerce is found in liquid form. In 
making solution for surgical purposes an ounce of this liquid is added 
to 20 or 40 ounces of water, according to the strength of the solution 
desired. Although phenol is soluble in 19.6 parts of water, solution 



540 REMEDIAL MEASURES OTHER THAN DRUGS 

does not take place immediately, and in making solutions of a 
strength of 1 : 20 either the water must be hot or a certain amount 
of time and considerable agitation of the mixture are required, 
otherwise globules of almost pure phenol are deposited in the bottom 
of the tray or vessel into which the solution is poured, and these, on 
coming in contact with the hands of the operator, exert an undesirable 
cauterant effect. 

The 1 : 20 solution at one time used for the disinfection of instru- 
ments and the cleansing of surfaces has now been abandoned except 
when other and better means cannot be obtained. If a phenol solu- 
tion is employed for irrigation or for cleansing compresses during an 
operation, it should not be stronger than 1:40. 

A property possessed by phenol, which renders it an unsafe medium 
for the impregnation of gauze, is its volatility. After exposure of a 
few hours to the atmosphere it wholly evaporates, leaving not an 
antiseptic but simply a sterile dressing. This fact is utilized by the 
surgeon in the preparation of the deeper layers of the dressing, which 
come in immediate contact with the edges of the wound. Since all 
antiseptics are more or less irritating to raw surfaces, healing will 
be promoted by a sterile rather than by an antiseptic application. 
By moistening in a phenol solution of 1 : 20 a piece of boiled and 
sun-dried gauze sufficiently large to cover the wound-edges, the anti- 
septicity of this dressing is assured, and in a very few hours the heat 
of the body causes evaporation of all the phenol, leaving a sterile, 
non-irritating surface in contact with the wound. 

Even in proper solution, phenol greatly irritates the hands of 
the surgeon, and if used in a strength of more than 1:40 causes so 
much benumbing of tactile sensibility that manipulative skill is 
seriously interfered with. The cracked and fissured fingers result- 
ing from the use of phenol lotions at times produce far more serious 
results than temporary pain and discomfort: many recesses are 
provided in the depths of which septic germs may successfully resist 
the action of antiseptic washes. Septic poisoning has been fre- 
quently due to this fact. Moreover, certain individuals exhibit an 
idiosyncrasy toward phenol, gangrene having resulted from a skin 
application of a strength not greater than 1:40. 

A 37 per cent, aqueous solution of formaldehyde gas is a powerful 
disinfectant, but when used in efficient strength is both painful and 
irritating. -In the strength of 1:2000, using normal saline solution 
as the diluent, it may take the place of bichloride lotion for flush- 
ing large cavities or cleansing extensive granulating surfaces. The 
vapor has its most useful application in disinfecting rooms, barracks, 
dressings, and instruments. 

Iodoform occupies a unique place among antiseptics in having 
been almost universally accepted and used by surgeons and clinicians 
in spite of the fact that its germicidal action has been proved by 
laboratory research to be practically nil. It is found that nearly all 



ANTISEPTICS 541 

forms of pathogenic germs grow abundantly upon culture materials 
the greater part of which is made up of iodoform, and that injections 
of such germs, mingled with large quantities of iodoform, produce 
their characteristic effect upon living tissues with almost as great 
certainty as though this drug had not been used; furthermore, it has 
been shown that iodoform is not even sterile, and that as employed 
by surgeons it is frequently a cause of infecting previously aseptic 
wounds; moreover, it is poisonous. In spite of this overwhelming 
evidence against it, the drug is still in favor. Recent researches 
have explained, in part at least, the reason for this contradiction 
between experimental and practical results. It has been well said 
that the human body is not a test-tube, and that bacteriological 
research cannot supplant the evidence of clinical observation. Elab- 
orate investigation has shown that this drug acts as a powerful anti- 
septic, not by destroying germs, but by undergoing a decomposition 
in their presence, the products of which render the toxines, the 
result of germ-growth, inert. In this way suppuration is, to a 
certain extent, inhibited, or if present, its disastrous effects upon 
the system at large are prevented, since these are due to toxine 
absorption rather than to a direct effect of the microorganisms 
themselves. It has been apparently proved that toxines, in them- 
selves, and without the presence of microorganisms, can generate 
pus, but that where such toxines are mixed with iodoform before 
infection no pus is formed. If these septic chemical compounds are 
rendered inert, a powerful adjuvant to the destructive action of the 
germ upon living cells is removed, and thus the system is often 
enabled to overcome one enemy where two would have prevailed. 
The fact that iodoform is in itself not sterile is, from a practical 
standpoint, most important. Fortunately, sterilization is readily 
accomplished. A thorough washing in a 1 : 1000 bichloride solution 
followed by a washing with freshly distilled water destroys all 
microorganisms . 

As employed in surgery, iodoform, after having been sterilized, is 
placed in small pill-boxes or wide-mouthed jars, over the opening of 
which is tied a single layer of antiseptic gauze; through this the 
iodoform is sprinkled as desired over wound surfaces. It is rarely 
used except in the treatment of chancroids and of tuberculous 
lesions. 

Dakin's Fluid.— Recent military experience has shown that 
Dakin's fluid is possessed of high antiseptic value, hence it has been 
extensively used for irrigation and the wet dressing of infected wounds. 

Long before we knew anything of microorganisms as factors in 
disease medical men knew that "Labarraque's solution," known 
officially as Liquor Sodw Chlorinates, arrested suppuration and was 
efficient in cleansing fetid sores. It did good because of its chlorine 
content. Instead of using chlorinated soda we generally employ 
chlorinated lime. This possesses, however, irritant properties 



542 REMEDIAL MEASURES OTHER THAN DRUGS 

because of its marked alkalinity, and as the chlorinated lime from 
which it is made is of varying strength as it is found on the market, 
the effects of the chlorine content were very variable. It is inter- 
esting to note how we at times miss a fact near at hand and after 
trying many routes or methods, arrive near our starting-point to 
find it is the best place after all if some slight but important modi- 
fication is made. The prime considerations in an antiseptic are that 
it shall be unfavorable to germs, not harmful to the cells of the 
body and that it shall not be expensive nor difficult to prepare and 
keep in an effective form. Furthermore, its consistency should not 
be such as to block drainage nor should it require very frequent 
changing. 

There is practically no substance known which meets these condi- 
tions, but Daufresne's modification of Dakin's solution, if prepared 
with proper precautions, without doubt far surpasses antiseptics 
which have been generally employed during the time that old- 
fashioned dilute Labarraque's solution was shelved. 

Dakin's original solution failed because of its irritating properties 
and uncertain results. It was made by dissolving 140 grams of 
dried sodium carbonate in 10 liters of water and adding 200 grams 
of chlorinated lime. This mixture is repeatedly shaken during a 
period of one hour when the supernatant fluid is siphoned off and 
filtered. As this fluid is excessively alkaline 40 grams of boric acid 
was added. 

Dakin's solution, as just stated, has a varying alkalinity and an 
uncertain content of chlorine. Daufresne has devised the following 
plan whereby these faults are set aside. Place 184 grams of chlorin- 
ated lime containing not less than 25 per cent, chlorine in a bottle, 
or flask, holding 12 liters and add 5 liters of water. Shake repeatedly 
during six hours. When preparing this solution make a second one 
by dissolving 92 grams of dried sodium carbonate and 76 grams of 
sodium bicarbonate in 5 liters of water. After the six-hour period 
referred to is ended add the sodium carbonate solution to solution 
No. 1. Shake the mixture well and then allow at least half an hour 
to elapse for full reaction to occur. Now siphon off the supernatant 
fluid and filter, when it is ready for use if the ingredients and technic 
have been perfect, but it must be kept tightly corked in a dark 
vessel and should not be used until after the lapse of seven days. 
To determine that the solution is not too alkaline, and therefore 
irritating, add to 20 cc of it 0.2 of phenolphthalein when, if the 
fluid is proper for use, there will be no red color. To determine if 
the chlorinated lime which is used is up to at least 25 per cent, 
strength, mix 20 grams of it with great care in 1 liter of water. Shake 
it occasionally during a period of several hours and filter. Pipette 
10 cc of the clear filtrate and add thereto 20 cc of a 1 to 10 
solution of potassium iodide and 2 cc of acetic or hydrochloric 
acid. Into this solution add drop by drop a decinormal solution 



ANTISEPTICS 543 

of sodium thiosulphate until the tested fluid is colorless. If the 
cc of thiosulphate solution required to decolorize is multiplied by 
1.775 the weight of available chlorine existant in 100 grams of the 
chlorinated lime is determined. If the chlorine content varies 
from 25 per cent, named above then the quantities of the various 
ingredients must be altered, and Daufresne has given these variations 
in the following table: 

QUANTITIES OF INGREDIENTS FOR TEN LITERS OF DAKIN's SOLUTION. 



Titer of 


Chlorinated lime, 


Anhydrous sodium 


Sodium bicarbonate, 


chlorinated lime. 


gm. 


carbonate, gm. 


gm. 


20 


230 


115 


96 


21 


220 


110 


92 


22 


210 


105 


88 


23 


200 


100 


84 


24 


192 


96 


80 


25 


184 


92 


76 


26 


177 


89 


72 


27 


170 


85 


70 


28 


164 


82 


68 


29 


159 


80 


66 


30 


154 


77 


64 


31 


148 


74 


62 


32 


144 


72 


60 


33 


140 


70 


59 


34 


135 


68 


57 


35 


132 


66 


55 


36 


128 


64 


53 


37 


124 


62 


52 



There are several essential points in regard to the use of this solu- 
tion if it is to produce adequate results. Commercial hypochlorites 
are usually inconstant and therefore each sample should be analyzed 
before it is used. The solution must be protected from light and 
heat. It must reach every part of the wound and infected spaces 
must be opened up so that this is accomplished. When every part 
is found to be sterile by cultures the wound may be closed and 
promptly heals. Through and through drainage does not do well 
as pockets escape irrigation. Irrigation is accomplished by multiple 
perforated tubes each placed in a pocket (Fig. 66). 

In order that the technical difficulties in the preparation of these 
chlorine solutions may be avoided a concentrated solution of hypo- 
chlorite of sodium is now placed on the market under the name 
"Hyclorite." With it and pure water an excellent solution of 0.45 
per cent, chlorine can be made in one minute. It is less prone to 
be unduly alkaline and so therefore less irritating than ordinary 
Dakin solution. 

Because of the obvious difficulties in the preparation and keeping 
of Dakin's solution toluene sulphondichloramine, in other words, 
toluene dichloramine, or "dichloramine-T," has been introduced as a 
substitute, depending for its very high germicidal action upon the 
large amount of active chlorine which it contains. Dichloramine-T 



544 



REMEDIAL MEASURES OTHER THAN DRUGS 



appears as a yellowish white crystalline substance, when made with 
chloroform, possessing rather a sweet odor with some pungency 
resembling chlorine. When made commercially on a large scale in 
vacuum it appears as a powder. When first employed it was used 
in a strength varying from 2 to 5 per cent., the solution having 
been made by dissolving it in a mixture of eucalyptol and paraffine 
oil. The use of this mixture was resorted to first because dichlora- 
mine-T is practically insoluble in water and the use of eucalyptol 
causes the chlorine to be given off slowly over many hours instead 
of all at once. Thus, while most of the chlorine may be lost from 




Fig. 66. — Apparatus for applying Carrel-Dakin solution. This apparatus is 
furnished by instrument dealers. A, reservoir graduated; B, clamp for regulating 
flow; C, sight feed cup; D, four-way glass distributor; E, perforated distributing tubes 
with ends tied. When used for surface ends are covered with Turkish toweling; 
F, five-way glass distributor; G, one tube glass distributor; H, two-way glass distributor; 
/, syringe for applying solution by hand; J, flask for use with syringe. 



Dakin's solution in a few minutes, the oily dichloramine-T solution 
lasts as many hours. The oil further acts as a protective dressing 
in itself and permeates all parts of the wound so that very small 
quantities cover a very large area. Any irritation of the skin can 
be avoided by using light dressings. 

Even when eucalyptol is employed the product, as already stated, 
soon becomes of uncertain strength. Dakin has improved upon 
the eucalyptol-paraffine mixture by treating any pure paraffine wax 
that melts at 50° C. or over, with chlorine gas, at a temperature of 
from 120° to 140° C. until an increase in the weight of the paraffine 
amounts to 45 to 55 per cent. Hydrochloric acid develops which 



ANTISEPTICS 545 

is removed by shaking with about 5 per cent, of dry sodium car- 
bonate and the hot oil is then filtered through dry fluted paper. 
It is now ready as a solvent of the dichloramine-T and is called 
" Chlorcosane" because the predominating hydrocarbons of solid 
paraffine are designated by terms ending in " cosane," the prefix 
"chlor" indicating the presence of chlorine. When making the 
solution of dichloramine-T in chlorcosane it is best to warm one- 
fourth of the latter to 80° C, then add the dichloramine-T, usually 
not in excess of 5 per cent.; and stir until it is dissolved, when the 
remainder of the chlorcosane at room temperature is added and 
filtered. When decomposition of the dichloramine-T in chlorcosane 
has occurred it shows an abundant deposit and the oil should be 
discarded. If soon after it is made it is found to be cloudy or pre- 
cipitated from exposure to cold it may be gently warmed when, if 
not decomposed, it becomes clear. Dichloramine-T in chlorcosane 
should be neutral in reaction because even a faint trace of acid 
rapidly decomposes it. Acidity can be determined by wetting a 
piece of blotting paper with ammonium water and holding it over 
the preparation. If acid is present opaque white fumes of ammo- 
nium chloride will be given off from the paper. 

Dichloramine-T is without doubt, up to date, the best wound 
dressing that we have, both as to cost and efficiency, particularly 
where large numbers of wounded are to be treated and it is so fre- 
quently made that there is always a supply of the fresh preparation 
on hand. As, however, it soon deteriorates when kept it does not 
lend itself as an antiseptic dressing to the private practitioner who 
only has an opportunity to employ it at long intervals. Sunlight, 
water and alcohol decompose chloramine, which must be kept in a 
dark amber glass bottle. Blue glass containers are not efficient 
because the rays of light which pass through it decompose the com- 
pound. So essential is it that no water shall come in contact that 
a glass pipette which has been sterilized by boiling and is still wet 
must not be introduced into the solution, because the minute amount 
of water adhering to the pipette will result in decomposition. (See 
Chloramine-T below.) A dry pipette is the best way to apply it. 
A very minute amount of the oily solution is required and it is a 
mistake to use it too freely. Dichloramine-T will fail as an antiseptic 
dressing if dirt, foreign bodies and pieces of bone are left in the wound. 
Use only a light dressing. 

Superficial wounds of large extent and burns may be treated by 
dichloramine-T according to the plan of Lee and Furness. They 
spray the area with a 1 to 2 per cent, solution in chlorcosane. Over 
this they place strips of paraffinized mosquito netting made in the 
following manner. Ordinary y^-inch netting is not washed to get 
rid of the sizing but sterilized by heat as are ordinary dressings. 
Pick up the strips of netting with forceps and dip in thoroughly 
melted paraffine wax which melts at about 50° C. Then lift them 
35 



546 REMEDIAL MEASURES OTHER THAN DRUGS 

out* of the wax and hold them, or hang them, over the heat so that 
the excess of melted wax runs off leaving the interstices open. Then 
cool and keep for use by wrapping in sterile towels. The method 
permits free drainage of secretion which the ordinary paraflfine 
method (see Burns, Part IV) of treating burns lacks and obtains 
the primary antiseptic properties of the dichloramine-T. 

Chloramine-T, not dichloramine-T, occurs as a white, crystalline 
solid without odor, containing 12.6 per cent, of chlorine. It has the 
advantage over dichloramine-T that it is soluble in water and this 
solution is quite stable even when exposed to light. It is because 
of its stability not so powerful a germicidal effect but is efficient. 
A 2 per cent, solution equals in value a 0.5 per cent, of Dakin's 
solution. This 2 per cent, solution may be kept in stock and diluted 
if desired with normal saline before using. 

Among the newer antiseptics should be named acriflavine and 
proflavine. Acriflavine occurs as a brownish-red, odorless crystal- 
line powder, soluble in less than 2 parts of water and forming a 
dark fluid. It is a moderately successful antiseptic used in a 1 to 
1000 solution of normal saline for washing wounds and infected 
cavities. In the latter case some of the fluid should be left in situ 
if possible. When large cavities are to be irrigated a 1 to 4000 solu- 
tion is employed. It has a somewhat greater antiseptic power than 
proflavine which is used in the same manner for the same purposes. 
An advantage claimed for both of these substances is that they act 
best in the presence of serum, which is a deterant factor in the case 
of most other antiseptics and that they do not interfere with the 
activity of the leukocytes which is a factor greatly to be desired. 
Stains of the skin caused by these dyes can be removed by washing 
the part in dilute hydrochloric acid solution and then with plain 
water. 

Kreolin is a preparation obtained from English coal by dry distilla- 
tion, and because of its feeble toxic action is often preferred to phenol. 

The extravagant claims advanced for kreolin in regard to its germi- 
cidal power have not been confirmed by bacteriological investigation. 
In solutions containing albumin it is not efficient as a germicide 
in strengths of less than 1 : 100, its power being somewhat less than 
that of phenol. 

Kreolin, though insoluble in water, readily forms an emulsion 
quite as efficacious in its antiseptic properties as a true solution. 
Since this emulsion is opaque, it is scarcely applicable for immersing 
and sterilizing instruments, the latter not being readily found. It is 
admirably suited, however, for cleansing the hands, a 5 per cent, 
solution neither cracking the skin nor benumbing the sensory nerves. 
In irrigating large wounds, cavities of the body, and particularly as 
a means of preventing sepsis or aborting it in gynecological work, 
kreolin can be warmly commended. It may be employed in a 
strength of from 0.2 to 5 per cent. 



ANTISEPTICS 547 

Among the many antiseptic agents of less importance may be 
mentioned Peroxide of Hydrogen. This drug comes in what is 
termed a ten-volume solution. By this it is meant that ten volumes 
of feebly combined oxygen are contained in each volume of the 
liquid. It is applicable, not to sterile surfaces, but to suppurating 
wounds and sinuses. It is used in the strength of from 50 per cent, 
up to full concentration. When this drug is poured into a suppu- 
rating sinus or cavity an ebullition takes place, which ceases only 
when the drug is exhausted or the dead material has been oxidized. 
It should never be used in a cavity from which the gas cannot readily 
escape. 

Chloride of Zinc has been extensively employed in some clinics as 
an antiseptic application. It is used in 10 per cent, solutions, and 
is applied when the field of operation is probably infected by pre- 
existing pus-formation. Although bacteriological research has shown 
that this agent possesses feeble antiseptic power, clinical experience 
demonstrates its value when applied to infected surfaces. Lately 
the Zinc Phenolsulphonate has to a great extent replaced the chloride, 
as it is less toxic and irritating and far more potent. 

For the sterilization of mucous surfaces a saturated aqueous solu- 
tion of Boric Acid is commonly employed. More potent than this 
are the silver salts, silvol, protargol, and silver nitrate in solutions 
of 1 : 2000 to 1 : 1000. (See articles in Part II.) 

An omission of the details of cleansing the hands of the surgeon 
and assistants in preparing for an antiseptic operation is scarcely 
permissible when writing upon the subject of antisepsis. The most 
approved method is as follows: 

The hands and forearms are thoroughly scrubbed in sterile water, 
using preferably green soap, cleansing the nails with an orange stick 
in the beginning of the scrubbing and during it. When practicable 
this cleansing should be done under a stream of running sterile water; 
when this is not possible the water in the basin should be changed 
three times for fresh sterile water. This scrubbing with soap and 
a brush should be continued for at least five minutes. Thereafter 
the hands are washed in alcohol (60 per cent.) for one minute and 
are then soaked in a solution of bichloride of mercury 1 : 1000 or 
biniodide of mercury 1 : 1000 for one minute, then dried by a sterile 
piece of gauze, and sterile rubber gloves are put on. 

A more rapid method of effecting disinfection, and one which, 
from a laboratory standpoint, has proved to be entirely efficacious, 
is by means of a mixture of chlorinated lime and boric acid in equal 
parts; a teaspoonful of this is added to a quart of water, and after 
preliminary cleansing with soap and water, the hands are immersed 
in this solution for fifteen seconds. 

Any method which irritates or cracks the skin of the hand is 
dangerous. The only certain way of avoiding infection from the 
hands of the operator lies in the use of rubber gloves. 



548 



REMEDIAL MEASURES OTHER THAN DRUGS 



ANTITOXIN. 

The method by which protection is obtained by the use of anti- 
toxic serum is best explained by the hypothesis of Ehrlich, which 
has withstood the test of scientific investigation very well and is 
now generally admitted to be the true explanation of this interesting 
subject. It is assumed that all cells have the power of combining 
with the food-products that are needed by them for sustenance by 
means of receptors or parts which have an affinity for each form of 
food required. A cell may have many of these receptors, each of 
which is suited to the appropriation of a definite kind of foodstuff, 
and is unable to appropriate or become attached to any other variety 
of food. As soon as a receptor has been utilized for the appropria- 
tion or attaching of a particle 
of food, the cell immediately 
makes another receptor, and, 
in many instances, makes a far 
greater number of these recep- 
tors than is necessary, partic- 
ularly if the demand is very 
great. These extra receptors 
are, when made in excess, 
thrown off into the blood, 
where they exist unattached to 
the cells which originated them 
(Fig. 67). 

The poisons or toxins of dis- 
ease are known to be complex 
proteid bodies closely resem- 
bling food bodies, and therefore 
these poisonous products of 
bacteria unite with the recep- 
tors of a cell, and instead 
of nourishing it, produce its death. An animal or a man may be 
naturally immune to a disease by reason of the fact that the cells 
in his body may be devoid of receptors capable of combining with 
a given poison, or by reason of the fact, which is the case in acquired 
immunity, that his cells have thrown off so many extra receptors 
into the blood that the toxins unite with them, and as they are 
unattached to cells the animal is not affected. These receptors are 
also called antibodies, and when serum of a horse is injected into 
the tissues of a child suffering from diphtheria, this serum contains 
so many antibodies or receptors that the toxins of the disease are 
locked in the embrace of the antibodies in such large numbers that 
the cells of the body itself are not overwhelmed by the infection. 
In the case of diseases such as scarlet fever and smallpox, which 
rarely attack the same person twice, it perhaps may be said that 




Fig. 67. — -Showing separation of receptors 
or antitoxins, and combination of toxins 
with free antitoxins. 



ANTITOXIN 549 

immunity is conferred by the tissues being trained or educated, as 
it were, to prepare antibodies in such large amounts when called 
upon that the entering wedge of a new attack is snapped off at the 
moment it begins to enter the field. 

That an actual combination takes place seems to be proved by 
the experiments of Martin and Cheny, who found that the toxin of 
diphtheria will pass through a Berkefeld filter covered with gelatine, 
whereas the antitoxin will not do so because its molecule is too large. 
If the toxin and antitoxin are mixed, the toxin ceases to pass through 
the prepared filter because, having united with the receptor, its 
molecule is too large. 

The horse, being naturally able to resist diphtheria-infection to 
the extent of complete immunity, it becomes necessary, in order to 
make the resistance of his blood serum absolute, to stimulate, if we 
may use such, a term, his antitoxin-preparing powers, and with this 
object in view injections of the toxin derived from cultures of diph- 
theria germs are made into the blood of the naturally immune brute. 
As result, the serum of the blood of the animal possesses the power 
of not only resisting diphtheria poison while in its own vessels, but 
also confers immunity of a temporary kind upon any other animal 
into whose body some of it is injected. It having been found experi- 
mentally that antitoxic horse serum when injected into the suscept- 
ible guinea-pig renders that animal to a great extent insusceptible 
to inoculation by diphtheria, it was but a step to the use of the same 
agent for the protection of a child. 

Besredka and others have seemed to prove that the danger of 
severe serum sickness or anaphylaxis can be foretold, and in many 
cases prevented by the preliminary injection of 1 or 2 cc of anti- 
toxic serum, following this testing dose by the full quantity some 
minutes later. (For Anaphylaxis see article on Diphtheria in Part 
IV.) 

A. number of antitoxic sera are now employed, although none of 
them give results equal to those produced by antidiphtheritic serum. 

Antidiphtheritic Serum. 

Serum Antidiphthericum Purification, U. S.— The following process 
is followed in its preparation: a pure culture of the bacillus of this 
disease having been grown, colonies of the bacillus are picked up 
off the culture gelatin and placed in tubes of blood serum, which in 
turn are placed in an incubator. After a time flasks of bouillon 
are inoculated by the germs. These flasks are then placed in an 
incubator, where there is rapidly produced the diphtheritic poison 
in the bouillon. After a length of time sufficient for the development 
of the poison the fluid has added to it a small amount of some pre- 
servative, and is then filtered through unglazed porcelain, whereby 
all the bacilli and other particles are separated, the filtrate being 



550 REMEDIAL MEASURES OTHER THAN DRUGS 

a clear, straw-colored fluid. This is the fluid containing the toxin. 
The toxin of each flask varies in its power, so it is necessary to deter- 
mine its activity. This is done by injecting it into guinea-pigs, 
which animals are very susceptible. Usually from 2 to 100 milli- 
grams are required to cause death within a few days. A young, 
healthy horse now receives about 1 cc of the toxin by subcutaneous 
injection; that is ten times the fatal dose for the guinea-pig, pro- 
vided the fatal dose was 0.1. Horses are chosen because they are 
naturally immune, have large amounts of blood serum, and are 
easily handled. Gradually increasing doses are given until the 
horse can readily receive several hundred times the first dose without 
any ill-effects. The horse is now capable of rendering antitoxic 
serum, and he is bled. The blood serum is separated and purified 
and is then tested to determine its power. The tests applied are such 
that the strength of serum is measured by units of antidiphtheritic 
serum. 

An antitoxin unit is the unit established by the United States 
Public Health and Marine Hospital Service. It can be defined 
approximately by the following description of the process used : Ten 
times the smallest fatal dose of toxin is injected into a guinea-pig, 
and at the same time 0.1 cc of the horse serum is injected. If the 
guinea-pig survives, the serum is said to contain 1 unit of antitoxic 
power in each milliliter, and as the dose given was only one-tenth 
of a milliliter it follows that each milliliter is ten times the amount 
of serum sufficient to protect a guinea-pig from ten times a fatal 
dose of toxin. If this strength of serum were used, very large doses 
would have to be given to get any effect in man; so we are not satis- 
fied with this result, and by continued dosing of the horse we may 
obtain, from his blood, serum which will be active in protecting the 
guinea-pig, not in the dose of 0.1 cc, but in the dose of 0.001 cc. Such 
a serum contains, therefore, 100 antitoxin units to the cubic centi- 
meter. A dose of 5 cc of this strength would, therefore, give 500 anti- 
toxin units. Even this is not satisfactory. Accordingly, most of the 
serum on the market is so strong as to contain 500 or even 1750 
antitoxin units in each cubic centimeter, so that 2 cc of the latter would 
be a dose of 3500 units. These very high-potency serums diminish 
in efficacy if kept for any length of time, but unless decomposed are 
to be employed when fresh antitoxin is not at hand, as they remain 
potent for many months. All serum of whatever strength should 
be obtained as fresh as possible. 

It has been found that the antitoxic substance is in the globulins 
of the serum or at least closely associated with them, and, therefore, 
there is now on the market liquid and dry Antidiphtheritic Globulin 
(Serum Antidiphthericum Siccum, U. S.), which is equally efficacious 
with ordinary antidiphtheritic serum, and can be given in about 
one-half the dose as to bulk. The dry form is dissolved in normal 
salt solution before injection. (See Diphtheria, Part IV.) 



ANTITOXIN 551 

A dose of antitoxin given after the lapse of ten days following a 
previous dose may rarely develop grave symptoms. (See Diph- 
theria.) 

Antidysenteric Serum. 

This serum is used only in bacillary dysentery and is of no value 
in amebic dysentery. The horse is employed to produce the serum 
and, as a rule, one animal is given cultures of the bacillus of Shiga 
and another horse those of the bacillus of Flexner. The antiserum 
made by the Shiga bacillus has little if any value if used against 
infection by bacillus of Flexner and vice versa. Therefore, if it is 
possible to determine, by laboratory technic, that either the bacillus 
of Shiga or that of Flexner is the cause of the illness the specific 
antiserum is to be employed, but as this is usually out of the question 
it is customary to mix, or pool, the antiserum derived from each 
horse, thereby making a polyvalent serum. Both sera not only 
neutralize the toxins produced but act as a protection against 
infection. 

Antidysenteric serum is usually given hypodermically in the dose 
of 20 cc for an adult or half of this for a child, but if the infection is 
severe the dose may be much larger and may be given intravenously 
in doses as large as 50 to 100 cc to an adult. Response is usually 
very prompt, the nervous symptoms improving in a few hours and 
the diarrhea and tenesmus decreasing in twenty-four hours. Some- 
times complete recovery occurs in less than a week if the case is 
treated early in the malady. If the serum is used after the disease 
has been present for several weeks so that the state is one of chronic 
bacillary dysentery, little if any good from the use of this serum 
ensues. Flexner states that in mild epidemics with a mortality of 
10 to 15 per cent, the serum reduces it to 1 or 2 per cent, and in 
some outbreaks with a mortality of 50 per cent, this treatment may 
result in the death-rate being only 10 per cent. Graham of the 
British Army advises that in toxic cases a 5 per cent, solution of 
glucose should be given intravenously. (See Intravenous Medica- 
tion and article on Diabetes.) 

When used as a prophylactic the dose is usually 5 cc but the 
protection endures for only about two weeks. 

Antigonococcic Serum. 

Antigonococcic serum, prepared from the blood of horses, is now 
recognized as a valuable remedy in the treatment of gonorrheal rheu- 
matism. It has not, for unknown reasons, proved of material value 
in the treatment of gonorrheal urethritis or epididymitis. The 
method of using it consists in injecting 2 to 12 cc of the serum 
intramuscularly, or hypodermically, at intervals varying from two 
to six days. The best site for the injection is the abdominal wall. 



552 REMEDIAL MEASURES OTHER THAN DRUGS 

It causes both a local and a general reaction in a few cases. The 
local reaction consists in dermatitis or urticaria and enlargement of 
the inguinal glands. The general reaction consists of a rise of 
temperature of from one to two degrees and a quickening of the 
pulse. All these symptoms disappear in about twenty-four to forty- 
eight hours. Doses of this serum given at long intervals rarely 
cause anaphylaxis, as does any foreign protein substance. (See 
Diphtheria.) 

Antimeningitis Serum. 

Flexner has produced an antimeningitis serum from horses, inocu- 
lated with the Diplococcus intracellularis and its products, which 
has proved itself capable of reducing the mortality of epidemic 
cerebrospinal meningitis about 60 per cent, if it is used early enough 
to protect the patient from well-developed lesions. This serum 
should be made from the two main types of meningococcus with 
some of its subsidiary strains. Some of the marketed strains have 
not been patented. The properly made serum not only saves life, 
but greatly decreases the frequency with which those patients who 
recover from the attack suffer from sequelae, such as deafness, blind- 
ness, and deformities. It causes the turbid cerebrospinal fluid to 
become clear, and seems to facilitate phagocytosis and to arrest the 
growth of the specific microorganism as well. Its effects are bacteri- 
cidal rather than truly antitoxic. The dose should be repeated 
daily to prevent relapses and to produce a cure. Antimeningo- 
coccic serum is not given hypodermically but intravenously and 
by intraspinal injection. (See Lumbar Puncture.) It is given 
intravenously, in the dose of about 100 cc, to combat the bac- 
teriemia of the disease, but as a meningococcemia is not always 
present and intravenous injections of this serum sometimes causes 
severe reaction (see Besredka's Method) it is best to withhold 
this method unless the coccus is found in the blood. Before it 
is injected intraspinally an amount of cerebrospinal fluid equal 
to the amount of serum to be injected should be allowed to flow 
out of the needle. Although the fluid withdrawn should be exam- 
ined microscopically and cytologically, to make the diagnosis certain, 
the serum should be immediately injected, as delay may be fatal, 
and even if the symptoms be due to the pneumococcus or the tubercle 
bacillus no harm will be done. While the puncture is being made 
and the fluid withdrawn the blood-pressure should be taken. If 
. the fall of blood-pressure equals 5 to 10 mm. the withdrawal should 
cease. So, too, when the serum is being introduced, if the pressure 
falls care should be exercised to be more gentle, and if the pressure 
falls as much as 15 or 20 mm. the injection had better be stopped. 
Sharp and marked blood-pressure variations can usually be avoided 
if the fluid is not allowed to escape too fast and the injection is not 
made too forcibly and rapidly. It should be introduced by the 



ANTITOXIN 553 

gravity method not by the syringe. The dose of the serum is meas- 
ured not by units, but by cubic centimeters. The first dose of 
antimeningitic serum varies from 5 to 20 cc for a child to 20 to 50 cc 
for an adult. Infants under one year of age should rarely be given 
more than 10 cc. The maximum doses for other ages may be con- 
sidered as follows: One to five years, 15 cc; five to ten years, 20 cc; 
ten to fifteen years, 25 cc; fifteen to twenty years, 30 cc; adults, 
50 cc. It is wise to leave the needle in place for some minutes 
after the injection is made to see if symptoms of too great intraspinal 
pressure develop in which case some fluid should be withdrawn. 

The injection of antimeningococcic serum may induce an aseptic 
meningeal irritation (meningismus) with fever and rigidity of the 
neck. If this is the case the injections should be stopped. If these 
symptoms are due to a relapse of the disease it should be continued. 
The question is settled by examining the spinal fluid which in men- 
ingismus contains its normal glucose and does not show meningo- 
cocci. If glucose is absent serum should be used. Turbidity is 
of little value as an aid in diagnosis under these conditions. 

Antipneumococcic Serum. 

It is now a recognized fact that the pneumococcus occurs in three 
definite and distinct types, and a number of irregular or inconstant 
types form a class called Type IV. The mortality varies greatly 
with the type, Type III being the most lethal, the death-rate being 
as high as 50 per cent. Fortunately this type is not a common one. 
Type I and II have a death-rate of about 25 per cent, and Type IV 
about 12 per cent. Up to the present time it has not been found 
possible to produce serum antitoxic to any type except Type I, and 
even this is still sub judice. For the accurate use of the serum for 
Type I a competent bacteriological examination to determine the 
presence of this particular coccus is essential and this, in many cases 
is impossible, as the delay in obtaining it is fatal. The serum if used 
must be given very slowly intravenously in a dose of from 50 to 100 
cc three or four times a day until marked improvement is manifest. 
The infection usually causes a sharp fall in temperature followed in 
some hours by a rise which calls for another dose. In Type I infec- 
tion it is claimed that Type I serum reduces the mortality from 25 
to 10 per cent. Some physicians have employed a serum repre- 
senting Types I, II, and III so as to combat all or any one of these 
types if present. This measure does not seem to have given very 
excellent results. Before the intravenous injection is given a few 
drops of the serum may be injected intradermally to determine if 
there is danger of anaphylaxis. If in about an hour a definite 
hyperemic area develops at the point of injection anaphylaxis is 
probable and if used at all the doses should be small and at first 
given hypodermically. (See Besredka's Method, p. 549.) 



554 REMEDIAL MEASURES OTHER THAN DRUGS 

Antipoliomyelitis Serum. 

Antipoliomyelitis serum is not on the market and when used is 
derived not from immunized animals but from human beings who 
have had the disease. The best serum seems to come from those 
who have recovered from an attack of the disease within a space of 
time varying from several weeks to two years, but serum has been 
used when as great a time has elapsed as thirty years. If a donor 
can be found he must be free from other disease. About 500 cc 
can be taken from an adult or 250 cc from a well-developed child. 
After the serum is separated from the clot it is inactivated at 55° C, 
tested to prove that it is sterile, and preserved by the addition of 
tricresol 0.2 per cent. It is then kept in an ice-box.. The earlier 
it is used the better. It is to be given intraspinally after being 
warmed to body temperature very slowly in the manner used with 
antimeningococcic serum. As much as 20 cc for a little child to 
100 cc for a child ten years should also be given intravenously. 
The treatments should be at twenty-hour intervals if rapid improve- 
ment is not occurring. 

Antistreptococcus Serum. 

As is well known, infection by the streptococcus produces the more 
severe forms of septicemia such as are met with in the puerperium, 
after injuries and operations, in erysipelas, and in association with 
such specific infectious processes as scarlet fever and diphtheria. In 
the latter diseases under these circumstances there is probably a 
double infection. While the theoretical basis upon which the use 
of this serum rests is good, the results from its use have not been so 
valuable, probably because in many instances the infectious process 
has not been solely due to this microorganism and the other disease 
organisms produce their effects uninfluenced by the serum used. 
The best results have been obtained from its use in puerperal and 
post-traumatic sepsis, but only in the presence of well-marked and 
positive streptococcic infection would the writer resort to it. Its 
method of employment is identical with that of diphtheria antitoxin. 
Care should be taken to obtain the serum from a reliable manu- 
facturer. It would seem probable that in some cases of ulcerative 
endocarditis this serum is the best treatment that can be used. The 
dose of this serum is usually 10 to 20 cc every twelve hours, accord- 
ing to the age of the patient and the severity of the infection. Doses 
of 50 to 150 cc have been given intravenously in severe cases. 

Antitetanic Serum. 

Antitoxin fails in many cases of tetanus because the tetanus toxin 
unites so rapidly with the cells in the spinal cord and brain that by 



ANTITOXIN 555 

the time the symptoms are present and the antitoxin is given the 
damage is past repair, and the antitoxic bodies cannot combine with 
the toxic bodies because they are already combined with the cells 
of the tissues. If tetanus antitoxin is given at the time the wound 
is received, it is as efficacious as is antidiphtheric serum in preventing 
diphtheria. (See Tetanus.) ^ The point is to give it early and in 
large amounts. If any early symptoms are present, 25,000 to 50,000 
units should be used at once; thus, 1500 units into and around the 
nerve running to the infected area, 10,000 units intraspinally, and 
25,000 or 30,000 units intravenously. 

These injections should be repeated every twelve or eighteen hours 
until improvement is marked. A blazing fire must be overwhelmed 
at once if life is to be saved. 

The minimum dose as a preventive is 3000 units. 

The definition of a unit of antitetanic serum is as follows: "An 
antitetanic unit is ten times the amount of antitetanic serum that 
will neutralize the L+ dose of tetanus toxin when the two are mixed 
together and injected into a test guinea-pig weighing 300 to 350 
grams." The L+ dose is approximately 100 times the minimum 
fatal dose. (L+ stands for lethal dose +.) It should be remem- 
bered that the neutralizing power of antitetanic serum is approxim- 
ately ten times as great as that of antidiphtheric serum, unit for 
unit. 

The U. S. Department of Public Health and Marine Hospital Ser- 
vice has decided that after April 1, 1907, antitetanic serum packages 
must bear the following statement: "This package contains 1500 
antitetanic units, according to the U. S. Government standard, 
approved April 1, 1907." It is official as Serum Antitetanicum, 
U. S., Serum Antitetanicum Purificatum, and Siccum, U. S. 

A very careless custom has arisen among some members of the 
profession in that they call any biological or bacteriological product 
used by hypodermic injection a "serum," thereby confusing in their 
own minds and the minds of the laity antitoxins, vaccines, phyla- 
cogens, protein bodies of various types, and even glandular extracts, 
This carelessness is not only to be condemned because it is an error 
in itself but also because, as all these products depend for their 
activities upon the different effects which they produce in the body, 
the erroneous use of the word "serum" leads to an indefinite con- 
ception of how each product acts and leads not only to empiricism 
but to failure to get good results. A serum contains an antidote to 
a poison, a vaccine (see Vaccines) stimulates the body to resist the 
specific germ present, and a glandular extract supplies the body 
with something which its own glands fail to produce in sufficient 
quantity for normal function. There is only one serum, properly 
so called because it is actually horse serum, which acts in a manner 
resembling that of a vaccine and that is antimeningococcic serum 



556 



REMEDIAL MEASURES OTHER THAN DRUGS 



which as already stated is not an antitoxin but causes the cells in 
the spinal fluid, when it is given, intraspinally to^ devour more of 
the meningococci, in other words, it increases the phagocytic power 
of the cells. 

BIER'S HYPEREMIC TREATMENT. 

Bier's hyperemic treatment depends upon the fact that when 
Nature attempts to combat an inflammatory or infectious process 




Fig. 68. — Shows elastic bandage in place around the arm, its ends tied with tapes. 
If the bandage is to remain on for a number of hours, it is advisable to apply a strip 
of adhesive plaster, to guard against the tapes becoming undone. Note the engorge- 
ment of the subcutaneous veins of the forearm, showing the effect it is desired to 
produce by the bandage. (Meyer and Schmieden.) 



she usually produces an active hyperemia in and about the part 
involved. In other words, by the use of a given piece of apparatus 
an attempt is made to aid Nature combat pyogenic infections by an 
added hyperemia. In applying this method, care must be taken 
not to interfere with the free circulation of blood. The circulation 
may be slowed, but not blocked, and if the apparatus applied cuts 
off the pulse in the distal part of the limb, it is capable of doing 
great harm. The method of producing congestion is by the use of 



BIER'S HYPEREMIC TREATMENT 



557 




Fig. 69. — Technic employed for the production of obstructive hyperemia at the 
shoulder-joint. The folded piece of cloth is placed loosely around the neck. A piece 
of stout rubber tubing, under the required tension, is fastened on top of the shoulder. 
Two pieces of bandage are attached to the rubber tubing in front and behind and 
tied in the axilla of the healthy side, pulling the ring thus formed well over toward the 
median line. (Meyer and Schmieden.) 




Fig. 70. — Suction apparatus for the elbow-joint. The illustration shows how 
the elbow, which when introduced was entirely extended, has been bent slightly 
by the suction process in consequence of the edema and hyperemia produced. The 
accompanying pain is very slight. (Meyer and Schmieden.) 



558 



REMEDIAL MEASURES OTHER THAN DRUGS 



bandages or various forms of vacuum apparatus. Thus, in the arm 
or the leg, an ordinary Esmarch bandage may be employed (Figs. 68, 
69, 70, 71, 72 and 73). About the shoulder a piece of rubber tubing 




Fig. 71. — Illustrates the application of Klapp's suction cup in a patient afflicted with 
carbuncle of the neck. (Meyer and Schmieden.) 




Fig. 72. — Shows the application of the large suction glass to the breast. Negative 
pressure is produced by the suction pump. (Meyer and Schmieden.) 



CARBON DIOXIDE SNOW 



559 



held in place by a bandage around the neck may be used; about the 
upper scrotum a piece of similar tubing tied or held together at the 
ends by a clamp may be applied. 




Fig. 73. — Showing the Bier apparatus for production of mobility in stiffened tendons 

and joints. (Kanavel.) 



CARBON DIOXIDE SNOW. 

Carbon dioxide snow is usually obtained from large steel cylinders 
of liquid carbon dioxide, these cylinders being obtained from manu- 
facturers of soda-water supplies. Another source is the smaller 
cylinder of liquid carbon dioxide sold by automobile-supply houses 
for the easy inflation of tires. One of these small cylinders usually 
provides enough snow for one treatment or for several treatments 
if the patients are seen one after another. The escape of the carbon 
dioxide, whereby the so-called snow is formed, is controlled by a 
small valve cock. This snow has a temperature of about 85° F. 
below zero. The object of employing this snow is to obtain the 
effects of extreme cold upon localized areas which need treatment. 



560 REMEDIAL MEASURES OTHER THAN DRUGS 

A very satisfactory manner of molding the snow so that it is easily 
applied is to tie or hold a piece of thick chamois skin over the nozzle 
of the cock in such a way that a small pouch or pocket is formed, 
and the tank is then tipped slightly so as to bring the liquid which 
the tank contains in direct contact with the cock. The snow collects 
in the chamois pocket and while in the chamois is molded by the 
fingers in any shape desired, or, holding it in the chamois skin, it 
can be cut or pared or shaped by ramming it in a hard rubfter mold, 
such as an ear or nose speculum. The operator's fingers are pro- 
tected from the intense cold by means of the chamois skin, and 
one end of the mold of snow is then placed against the diseased area 
and held therefrom ten to thirty seconds, or longer if the disease is 
deep-seated. When used from ten to thirty seconds it acts as a 
stimulant. When a destructive or cauterant action is desired it is 
applied from thirty seconds to a minute. On removing the pencil, 
the area to which it has been applied is seen to be depressed, and 
frozen white and hard. Around this frozen area is a slight, narrow, 
zone of erythema. Thawing takes place in a minute or two, the 
part becoming red and sometimes slightly swollen. Later on, small 
vesicles or blebs form, which, if need be, can be punctured. Several 
days later slight exfoliation, or thin crusting, takes place. After a 
time the scab drops off, leaving a very slight scar, or, perhaps only a 
mere white mark, the permanent lesion depending, of course, upon 
the severity of the action. Large areas should not be exposed at 
the same time, but small spots should be selected for each treatment. 
Therapeutically, carbon monoxide snow is used by dermatologists 
in treating lupus erythematosus, and in varied types of angioma, par- 
ticularly in those cases which present small circumscribed elevated 
spots, as in early infancy. , It does less well in the so-called port 
wine marks. It is also sometimes employed to remove the brownish 
or dark spots forming on the hands and face of elderly people, and in 
certain cases of superficial epithelioma. It has also been employed 
in xanthoma. 

CLIMATIC TREATMENT. 

(See Mineral Springs and Climates, page 622.) 

COLD AS A REMEDY. 

Cold, or the rapid abstraction of heat, is a remedial measure that 
is nearly always available, and is possessed of very great power for 
good in properly selected cases. We may divide its use into its 
local application, for a superficial, limited, deep-seated, or distant 
influence, and its general application for the purpose of affecting the 
entire body. 

When cold is applied for its limited and local action, it is always 
used with two objects in view— namely, to cause localized contrac- 



COLD AS A REMEDY 561 

tion of bloodvessels which through inflammation are engorged so 
that the parts are reddened and swollen, or temporarily to anesthetize 
or benumb a nerve-fiber for the immediate relief of pain, and with 
the hope that the temporary paralysis may ultimately result in such 
nerve-changes as to produce a cure. 

Cold, in some form, is a popular remedy for a burn or sprain or 
any injury likely to be followed by inflammatory processes. In some 
cases, it is true, hot water or dry heat is equally efficacious, and this 
fact will be referred to when speaking of heat. (See Heat.) It may, 
however, be stated, as an almost invariable rule, that the choice of 
heat or cold is to be governed by the sensations of the patient (except 
in fevers), who will generally assert that one of the two is the more 
agreeable. 

Cold or heat causes relief of pain in inflammation by producing 
contraction of the local bloodvessel walls. As a result, inflammatory 
exudates do not occur, congestion is relieved, and as the pressure on 
the nerve filaments ceases the pulsating pain of inflammation passes 
away. 

A very useful remedy for the sprain of an ankle when it is a recent 
accident is to let the patient sit with the foot elevated, with a cloth 
wrung out in ice-water and an ice-bag applied over the part affected. 

In the treatment of localized pain or inflammation cold is used in 
a number of ways, largely depending in their choice on the will of 
the physician and the means of the patient. The simplest, cheapest, 
and perhaps the most efficient method of using cold is to place cracked 
ice in a pig's or sheep's bladder or rubber bag, and, after tying its 
neck to prevent leakage, to lay it over the inflamed part, surrounding 
it with a towel, so as to prevent the moisture, which appears on the 
surface from condensation, from wetting the clothing. 

Where a very limited and comparatively transient effect is needed, 
chiefly for anesthetic purposes, it is customary in hospital and private 
practice to use a piece of ice sprinkled with a little fine salt, and held 
against the skin by means of a towel in the hand of the physician. 
Actual freezing can often be produced very rapidly in this manner. 
Where a more rapid method is desired, sprays of various very volatile 
liquids may be driven against the part by an atomizer. One of the 
most readily employed of these liquids is ether, which is fairly effec- 
tive if it is used in a fine spray and driven against the skin in such a 
way as to favor rapid evaporation. Another of these agents is 
rhigolene, which is one of the lightest and most volatile of the liquid 
products of coal-tar, and is used in a spray from an atomizer in the 
same manner as is ether. Chloride of ethyl is a liquid largely used 
as a substitute for rhigolene as a local anesthetic through the intense 
cold produced by its evaporation. The fluid is directed against the 
skin over the involved area by means of a nozzle attached to the 
cylinder containing it. (See Ethyl and Methyl Chloride.) 

It is hardly necessary for the writer to repeat that, as the last three 
36 



562 REMEDIAL MEASURES OTHER THAN DRUGS 

liquids are very inflammable, they should not be used near a light or 
fire. (See also Carbon Dioxide Snow.) 

Aside from the local effects of cold on inflammatory processes, it 
is largely resorted to for the relief of neuralgia of a superficial type, 
and has often been used for the cure of deep-seated neuralgias, as 
over the course of the sciatic nerve in sciatica. Generally, however, 
it is employed in neuralgia of the supraorbital nerve, where, owing 
to the superficial position of these fibers, the cold can readily reach 
them. The skin should be distinctly whitened and blanched, and 
even hardened, by the cold before its application is stopped, and if 
one application does not cause a cure, it may be repeated every day 
for several weeks in obstinate cases. Sometimes cold is used to 
benumb the skin or subcutaneous tissues in cases where a minor 
surgical operation is to be performed, but the pain of freezing an 
inflamed part is often as great as that of the operation itself without 
an anesthetic. Freezing is valuable when the physician is using the 
actual cautery, and in all these cases may be employed as is indicated 
above. 




Fig. 74. — Showing the application of the cold-water coil to the chest in croupous 
pneumonia or pleurisy. Applied to the left side it may be so used in pericarditis in 
place of the ice-bag. By suction on the lower end of the tubing a stream of water 
flows from one bucket to the other, and when the water has been transferred the 
stream may be reversed by changing the level of the buckets. 

In endocarditis, and especially in pericarditis, the use of an ice-bag 
placed over the heart is a valuable remedial procedure, for it relieves 
palpitation and quiets the heart, decreases the pain and diminishes 
the inflammation. It is also useful for cardiac palpitation and for 
the rapidly acting heart of fever during the course of pneumonia or 
typhoid fever. 

Cold affusions to the head and, better still, the use of an ice-bag 
have long been highly regarded in the treatment of meningitis and 
head injuries; and a hot bottle to the feet and cold to the head will 
often induce sleep in persons who habitually suffer from insomnia. 



COLD BATHING 



563 



This is particularly the case with those individuals who are wakeful 
from mental overwork. On the other hand, cases with insomnia 
from cerebral anemia do well if a cold plunge-bath is taken before 
goint to bed, although in still other, cases a hot bath is more effica- 
cious. (See Heat.) The latter instances are not due to anemia, 
but to nervous irritability, which the heat quiets, whereas the insom- 
nia of cerebral anemia is relieved by a cold plunge by reason of the 
increased circulatory activity and equal distribution of the blood 
produced by the bath. 

When cold is to be applied to the head continuously, it is often 
convenient to employ a coil of rubber tubing and so shaped as to 
fit the vertex. One end of the tubing should reach to a tub of cold 
water on one side of the bed and the other to an empty tub on the 
other side. By sucking ( on one tube siphonage is established, and 
as soon as the liquid has been transferred from one tub the full tub 
is raised, the stream is reversed, and the water passes back to its 
former receptable (Fig. 75). 




Fig. 75. — Showing the application of the cold-water coil to the head in cerebral 
congestion, headache, meningitis and in fevers. 

Cold water dashed or sopped against the perineum or the scrotum 
and the lumbar region is a favorite remedy with some practitioners 
for nocturnal seminal emissions, and the scrotum may be submerged 
in a tumbler of cold water for a few moments at night for a similar 
purpose. 

COLD BATHING. 

The use of a cold bath for the purpose of increasing the tone of 
the system is as old a custom as any which we have, but, like all other 
things in medicine, cannot be Used without distinct indications for 
its employment, or, to speak more correctly, the absence of certain 
contraindications. The most universal exception to its use which 
we find is that class of persons with whom prolonged bathing of any 



564 REMEDIAL MEASURES OTHER THAN DRUGS 

kind, particularly when it is frequently repeated, does not agree. 
The writer is sure that a much larger number of persons belong to 
this class than is generally recognized, and he has seen cases of 
nervous exhaustion and general loss of vivacity and vitality occur 
as a result of too frequent bathing. This is the case more especially 
with daily bathers who soak themselves in hot or warm fresh water, 
particularly if the bath be taken in the morning. 

Before passing on to the consideration of the physiological action 
of a bath, and why and when a bath should be used, it is proper to 
call attention to the fact that a very large proportion of children who 
are bathed daily are allowed to lie and soak in the tub, and as a 
result become debilitated and fretful, only to recover when a brisk 
bath is used once or twice a week, and replaced in the interval by a 
nightly sponging with salt and whisky or salt and water. 

Through practical experience and much experimental research of 
a reliable character we now know that the following phenomena 
accompany the use of a cold bath in a healthy person with whom 
such a bath agrees: 

On entering the water he shivers, thinks it almost unbearably cold, 
and he gasps if the cold suddenly touches the belly-wall or an equally 
sensitive surface. In a moment, however, reaction sets in, and the 
extremities, heretofore trembling and covered with cutis anserina, 
become warmer and flushed. The pulse is increased in force and 
frequency, and the respirations are deeper and more thoroughly 
performed. As a result of this each portion of the body receives a 
more perfect supply of blood and feels rejuvenated. Following this 
stage of exhilaration, a third stage comes on, in which the dullness 
and depression of the first stage recur in an exaggerated degree, but 
this condition does not ensue unless the person remains too long in 
the water. If he leaves the bath while in the acme of exhilaration, 
the stimulus may remain with him throughout the rest of the day. 

The reason for the occurrence of this train of symptoms is not far 
to seek. The chilliness of the first stage shows that the great abstrac- 
tion of heat is lowering the bodily temperature, the centers for calori- 
fication in the body not producing sufficient heat for the preservation 
of the normal temperature. At first the cold drives the blood into 
the warm recesses of the body, leaving the surface cold; but in a few 
moments the system is aroused to the recognition of the fact that 
it must increase its exertions in the propulsion of blood and pro- 
duction of heat, and so with an effort it puts forth its energies, 
picks up each corpuscle in the internal organs that is hiding from the 
cold, and, after imbuing it with warmth obtained by increased heat- 
production in the sources of heat-manufacture, forces it out to the 
surface of the body along with its fellows, which are driven to all 
parts of the system. This is not a mere figurative way of putting 
the matter, for cold primarily always contracts bloodvessels and 
reflexly stimulates the vital centers to increased activity. 

When the bath is too prolonged, the result of overstimulation 



COLD BATHING 565 

ensues, and the depression of the nervous system and circulation 
may be sufficient to interfere greatly with normal functional activity. 

Just at this point it becomes clear why persons "catch cold," 
or, technically speaking, suffer from local or general congestions. 
An individual who is weak may never reach the stage of stimulation 
just spoken of, because his system has not enough units of force 
in it to expend them upon the functional activities named, and, as 
a consequence, the blood, which at the first shock has hurried into 
the internal viscera, is not driven back to its duty, but, sulking in 
its retreat like a deserting soldier, allows disaster and disease to 
ensue because its superior officer, the central nervous system, can- 
not gather together enough force or authority to make it do its 
duty. These cases present evidences, therefore, of circulatory and 
systemic depression or have congestion of the lungs, liver, or other 
parts. In the strong person exactly the same state of affairs obtains 
in the third stage of depression, but only after the strength of the 
system has been expended in the activity of the stage of exhilaration. 

Cold salt baths, particularly if they are sea baths, are more stimu- 
lating and not so relaxing as is fresh-water bathing. 

The use of a cold bath after a person becomes heated is popularly 
supposed to be dangerous. On the contrary, every athlete knows 
that nothing is so refreshing and so preventive of muscular stiffness 
after severe exercise and sweating as a cold plunge- or shower-bath; 
but he also recognizes the fact that a plunge is all that is permissible, 
and it is only the person who possesses the healthy circulatory power 
which will enable him to rebound from momentary depression to 
increased activity that should resort to such procedures. 

The tonic effect of the so-called drip-sheet in certain neurasthenic 
cases is most marked. As has been pointed out, reaction must be 
produced, since it is by the stimulation of the circulation and its 
readjustment or equalization that good is achieved. The duration 
of the use of the drip-sheet and the temperature of the water in 
which it is wrung out are governed by the ability of the patient to 
react. Very feeble patients must be gradually trained by moderate 
means to the colder temperatures, and, if need be, may stand in 
a tub containing a few inches of warm water if there is a tendency 
to coldness of the feet. 

The patient being stripped, the nurse takes a linen sheet previously 
dipped in water at any temperature that is not too low for reaction 
to take place, and throws it around the patient's body and over the 
head, so that in a moment the entire surface is in contact with it. 
Then the nurse applies brisk friction all over the patient's body 
and limbs, while the latter rubs the front of the body with his own 
hands. The whole performance is over in a few moments, and the 
patient should then lie down, be lightly covered, and rest. Such a 
drip-sheet will often be a cure for insomnia depending upon faulty 
cerebral circulation or nervous tension. In other instances it seems 



566 



REMEDIAL MEASURES OTHER THAN DRUGS 



to be stimulating and to arouse dormant functions. Once a day is 
usually sufficiently often to use it, and when treating neurasthenics 
the morning is generally the best time to employ it unless it is 
designed to cause sleep (Fig. 76). 




Fig. 76. — Drip-sheet wrung out and thrown about the patient, who rubs himself in 
front while the attendant applies friction to the back of the body and limbs. 



Cold in Fevers. 

The proper manner to employ cold water externally in fever should 
be thoroughly understood. It may be used at varying temperatures, 
according to the effect desired, such as cool, moderately cold, and 
very cold. 

Very commonly in the course of a fever the patient is restless, 
uncomfortable, and sleepless, yet has not a temperature fraught with 
harm. Such a case may be sponged with tepid water or with alcohol 
and water, or salt and whisky, with great benefit in the production 
of sleep, the reduction of fever, and the advantage of nervous quiet. 



COLD BATHING 567 

Sometimes the sponging is successful when used only over the arms 
and legs, but more frequently it should be extended at least to the 
spinal column. 

If tepid sponging does not lower the fever in a given case, then 
ordinary cool tap-water should be employed; and it is well to remem- 
ber that the secret of successful sponging lies in the use of a sponge 
not saturated to overflowing, but only sufficiently wet to leave a 
thin film of moisture on the skin, which cools the patient by its rapid 
evaporation and does not wet the bed-clothes. 

When we come to a study of the use of cold water in prolonged and 
severe fevers we find that its use is now universally recognized as the 
proper treatment, and with good reason. At one time it was 
believed that all the good results from cold bathing were due to the 
reduction of the fever, but it is now known that this is the least 
important effect of the bath except when there is such a hyperpyrexia 
that there is danger from that source. The benefit derived from the 
external use of cold water in infectious fevers rests upon the stimu- 
lation of the vasomotor system and general circulation, so that local 
stasis or congestions of blood do not occur in vital organs, in the 
stimulation of the processes of oxidation and nutrition, and in the 
elimination from the body by the skin and kidneys of toxic materials. 
Further, the more frequent cleansing of the skin aids its normal 
function, prevents chafing and bed-sores, and lowers the temperature 
by aiding in the dissipation of heat directly and through the sweat, 
which, even if imperceptible, is an important factor in reducing 
body-heat. 

Whenever cold is used for the reduction of fever and applied to 
the entire body, it should be applied rapidly and be accompanied 
by active rubbing of the skin of the entire body to bring the hot 
blood to the surface and to gain the valued effects of massage. As 
a rule, the water should be used at one temperature, and better 
results will be obtained if it is cold enough to produce something of 
a shock to the circulation and nervous system, for the effect sought 
is the production of a "reaction"— that is, a redistribution of the 
blood and an awakening of all the vital processes. For this reason 
the writer does not approve of graduated baths— that is, the use 
of water which is gradually cooled while the patient is being b athed. 
The whole idea of the cold-bath treatment of fever is to produce the 
reactive stimulating effect sought by the well man who takes a sea 
bath. Consequently individuals too feeble to react should be bathed 
in slightly cooled water at first, and the temperature of the water 
reduced each day a few degrees until it is quite cold. The exact 
degree of cold depends upon the need of the patient as stated below. 

Fever is then to be reduced by cool sponging, in old and feeble 
patients using water at 90°, 80°, or 70° F., according to the ability 
to react and the needs of the patient. Friction is to be used with 
one hand while the sponging is done with the other. 



568 



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CO to 



570 REMEDIAL MEASURES OTHER THAN DRUGS 

If the patient is a young adult and sufficiently strong to react, 
than the water used should be from 70° to 32° F., according to the 
needs of the case; and if the fever is persistent and difficult of reduc- 
tion, the nurse may rub a piece of icg over the skin rapidly, applying 
friction constantly with the other hand. 

The patient should always be stripped and laid on a blanket spread 
over a rubber sheet which has been placed to protect the bed. 

It is essential when sponging is used that more of it be applied to 
the back than the front of the body, for at the back the great muscles 
and thick skin retain the heat, and these parts are not cooled if only 
the front of the body is sponged. Further, the posterior surfaces 
are the ones apt to be congested and sore from the dorsal decubitus, 
and therefore need the stimulant effect of the bath, as do the kidneys 
and other deeply situated organs. That this treatment is of value 
in those who react is shown by the marked redness of the skin, the 
improvement of the circulation and respiration, and the cleared 
mind. 

The use of the ice-rub with a piece of ice weighing about two 
pounds held in the nurse's hand requires more care than does the 
immersion bath, but I have yet to see the case of typhoid fever, 
after the first week, in which this plan failed to reduce the tempera- 
ture if it was properly employed. Indeed, I have learned that when 
this method fails it is because the nurse does not know how to use it. 
The rubbing with the ice and with the other hand must be brisk 
and produce reaction. 

In some cases where sponging is not efficient the patient may be 
placed on a small canvas cot placed by the side of the bed and covered 
by a large rubber cloth, which, by being raised at the head and 
depressed at the foot, forms a channel for the water. Over this, 
again, is placed an ordinary sheet. The patient, after being stripped, 
is laid upon this sheet, which is then folded over him, and a spray 
from an ordinary watering-pot for flowers allowed to play upon his 
body from head to feet. The temperature of the water depends 
upon the effect required. The cot should be so arranged that the 
water will not remain in puddles under the patient, but drain off 
into a bucket at the foot. The sheet being wet allows evaporation 
to go on, and a rapid fall in the fever results. It is of the greatest 
importance that the attendant lightly but briskly rub the patient 
all over with the hands during this bath, so as to bring the blood to 
the surface and prevent internal congestions. 

If the fever cannot be reduced to 101° F. by the methods of bathing 
just detailed, the patient should be subjected to the cold plunge 
or tubbing, the so-called " Brand bath/' which has been employed 
almost exclusively in typhoid fever. The chief object sought by its 
use has already been described in discussing the effect of sponging. 
This object is reaction. 

The method consists in immersing the patient every three hours, 



COLD BATHING 571 

if his temperature reaches 102° or 102.5° F., in a bath-tub of water 
at 70° F. and allowing him to remain there under friction for fifteen 
or twenty minutes, or until his temperature is reduced to 101° or 
100° F. Before the patient enters the tub he is often given J to 1 
ounce (15.0-30.0) of whisky in a little milk or water to prevent 
depression. The patient will generally complain bitterly of the 
cold, particularly at first, and will also appear blue and chilly after 
the bath, but these signs are not so dangerous as they are alarming. 
If there be persistent and prolonged coldness after the bath, then 
hot bottles may be applied to the feet and a little whisky or brandy 
given. During all hinds of bathing an ice-bag should be kept to the 
head to prevent cerebral congestion. 

When the tub is used, it should always be placed near the patient's 
bed, so as to avoid unnecessary disturbance and muscular effort, 
for his strength must be conserved. 

In using the Brand bath, a patient should be lifted with care and 
gentleness from the bed to the tub. The water in the tub should be 
deep enough nearly to cover his body, and yet not so deep as to 
float him in the tub so that he feels uncertain of his position and 




Fig. 78.— Bath stretcher. (F. E. Hare.) 

has to continually exert himself to keep his head above water. The 
lifting of a full-grown man into a tub, unless some mechanical aid 
is employed, requires several assistants, and, even when they are 
present, is very often a strain not only upon the nurses, particularly 
if a number of patients have to be bathed, but upon the patient as 
well. It is very important that patients should not exhaust them- 
selves by making efforts under these circumstances. A number of 
devices have been invented for the transfer of the patient from the 
bed to the bath. Probably the simplest and best is that employed 
by F. E. Hare, of Brisbane, Australia, as it is inexpensive and can 
be employed by two persons unless the patient is unusually heavy. 
It consists, as shown in the accompanying figures, in a perforated 
board, from which the water readily drains when the patient is 
lifted from the bath. This board has a loose piece at the top, which 
by resting on the head of the tub prevents the patient's face from 
being immersed. A rubber sheet having been placed on the bed by 
the side of the patient, the board is laid on top of it, and the patient 
is then readily slid by a lateral movement on to the board, lifted up, 
and immersed in the tub. After the bath is over, the board is 



572 



REMEDIAL MEASURES OTHER THAN DRUGS 



lifted, with the patient upon it, as high as the edge of the tub, a 
loose piece of board is slipped transversely across the foot of the tub, 
and on this and on the head of the tub rests the board upon which 




Fig. 79. — The use of F. E. Hare's bath stretcher. First stage. 




Fig. 80. — The use of F. E. Hare's bath stretcher. Second stage. 



the patient is lying. In a few minutes the excess of water drains off 
into the tub, and the board is then lifted on to the patient's bed, 
which is still protected by the rubber sheet. The patient is then 



COLD BATHING 



573 



slid off from the board on to the bedding and the necessary handling 
is completed. 




Fig. 81.— The use of F. E. Hare's bath stretcher. Third stage. 




Fig. 82.— The use of F. E. Hare's bath stretcher. Fourth stage. 

On the removal of the patient the surface should be gently dried 
with towels, and the bed-clothing consist of only a sheet, or a sheet 
and one blanket in cold weather. Above all things, it must be 



574 REMEDIAL MEASURES OTHER THAN DRUGS 

remembered that the patient is not to be wrapped in a blanket, and 
not only this, but that he must not be rolled in a blanket while still 
in a wet sheet. 

The wet sheet, if surrounded by a blanket, soon places the patient 
in a typical Russian or warm moist bath, calculated to raise instead 
of lower the fever. 

When a patient comes under observation as late as the third week 
of typhoid fever the cold bath is contraindicated, as a rule, because 
the patient does not react, owing to his feebleness. If the bath 
is used from the beginning of the illness, it may be used all through 
the attack, as the system is then trained to react and is rarely so 
asthenic. Other contraindications are intestinal hemorrhage, nephri- 
tis, and great cardiac feebleness, but pneumonia is thought by some 
not to be a contraindication. With this view the writer disagrees. 
This bath is contraindicated in croupous and catarrhal pneumonia. 1 

The fever of enteric fever does not readily yield under the use of 
the bath in the first days of its course, whereas that of other maladies 
usually does do so. This is an important differential point. 

All cases of typhoid fever should receive the cleansing and reactive 
effects of sponging and rubbing at least once a day, even if the fever, 
is not sufficiently high to need reduction. 

Whenever cold is used in febrile cases a thermometer should be 
placed in the mouth or pushed deeply into the rectum, and the fall 
in the temperature watched. As soon as it reaches 101° or 100° F. 
the bath must cease, lest the fall continue, reaction fail, and collapse 
ensue. 

Where sunstroke (thermic fever) is present the patient may have 
ice rubbed over his body or be put directly into a bath-tub of ice- 
water; but in any event the attendants must rub the patient's skin 
to bring the hot blood to the surface and prevent congestions. Cold 
water may also be injected into the bowel in cases where the skin 
is cold but the central temperature very high. (See Enteroclysis.) 

The treatment of rheumatic hyperpyrexia by cold is quite as suit- 
able as is this treatment of other fevers when the hyperpyrexia is so 
excessive as to endanger life. 

Baruch, the apostle of hydrotherapy, has expressed some views 
in the following emphatic "Dont's," with which the author most 
heartily agrees : 

Don't bathe with cold water to reduce temperature, but to refresh 
the fever-stricken patient. 

Don't permit cyanosis or chattering of teeth; stop! 

Don't stop bathing because patient complains of chilliness, unless 
the teeth chatter. 

Don't raise bath temperature on the latter account; shorten bath 
and increase friction. 

1 For a careful resume of the "Real Value of the Brand Bath in Typhoid Fever," 
by the author and Dr. C. A. Holder, see the Therapeutic Gazette, March 15, 1898. 



LOCOMOTOR ATAXIA AND MYELITIS 575 

Don't neglect friction during every cold procedure; it prevents 
chilling. 

Don't disregard the well-ascertained fact that the Brand bath (of 
65° to 70° F. every three hours when awake, with active friction), 
is the ideal bath for typhoid fever only. 

Don't give up cold bathing because the ideal bath is not obtain- 
able; other procedures are useful. 

Don't use the ice-coil to the abdomen; it has no refreshing effect 
and renders the skin beneath it cyanotic. 

Don't lose sight of the fact that the chief aim of all cold procedures 
is reaction. 

COORDINATED MOVEMENTS FOR TREATING LOCOMOTOR 
ATAXIA AND MYELITIS. 

This plan of treatment is based upon the fact that great improve- 
ment in locomotion on the part of ataxic patients can be produced 
by causing the patient to make certain definite movements, the 
object of which is to reeducate his coordinating power. The power 
of coordination is lost partly by reason of the disease in the nerves 
and spinal cord, and partly because the patient has become bed- 
ridden, so that his otherwise healthy tissues waste from disuse. 
Definite exercises in such cases perhaps train collateral nerve-centers 
and nerve-tracts to do work not usually part of their function. In 
any event, such patients often greatly improve under this procedure. 

It is vitally important that the various movements should be 
made slowly and with as great nicety as possible. 

Exercises for the Lower Limbs.— The patient lies on his back on a 
firm couch and slowly lifts his fully extended leg until he touches 
with his toes the finger of an attendant, who holds his hand at a 
distance of from eighteen inches to two feet above the bed. These 
exercises should be repeated several times with each leg. 




/■ I 4 I 31' 4] 




i si 




n 



A 



Fig. 83. — Showing the pigeon-holes into which the patient puts his heels when training 
his coordination and muscle-sense in locomotor ataxia. 

Next, the patient completely flexes the leg on the thigh, and then 
the thigh on the abdomen. After this the limb is slowly extended 
until the toe once more touches the finger of the attendant, the leg 
being elevated at the same time that it is extended. After making 
this contact the extended limb is slowly lowered until it rests on 
the bed. 

A third exercise consists in having a board made with pigeon-holes 



576 REMEDIAL MEASURES OTHER THAN DRUGS 

attached to it, the tops of the pigeon-holes being taken off. A dozen 
of these holes should be made, and either lettered in the order of the 
alphabet or numbered consecutively. The patient lying on the back, 
with the heels resting in two of these pigeon-holes, is directed to 
raise a leg and to lower it so that the right heel will come down in 
the pigeon-hole named by the attendant; so that if the right heel is 
resting in pigeon-hole 1, it may be placed in pigeon-hole 4; and after- 
ward the left heel, which may be resting in pigeon-hole 7, is placed 
in pigeon-hole 6. It will be readily seen that following these direc- 
tions trains the coordinative faculty. The edges of the pigeon-holes 
should be smooth, and perhaps padded, to prevent the heel from 
being injured by striking against them. 

The standing exercises consist in endeavoring to stand with the 
eyes closed and the feet close together, and in trying to stand on one 
foot with the eyes open or closed. 

Another exercise is to paint a black stripe a foot wide across the 
floor of a room, and to direct the patient to walk along this stripe 
with or without support, being careful to keep his feet within its limits. 
He will usually do better with bare feet than if he has his shoes on. 
In taking this exercise the patient should be directed to bring the 
foot down in the natural position, and not upon the heel, as is so 
commonly done by tabetics; and also he must not evert the toes 
too much in walking, as is so commonly the habit. As the patient 
improves, the stripe upon which he walks may be narrowed. 

The next walking exercise consists in going up and down stairs. 
It is well to build a flight of stairs, consisting of five or six steps, 
with a platform, which is so securely built that there is no danger of 
a fall. A balustrade or railing is put on each side of the steps for 
lateral support, and the patient is then made to ascend and descend 
the steps. Care must be taken that he mounts the successive steps 
by a proper contraction of his quadriceps rather than by pulling 
himself up by the aid of his hands. Many tabetics simply place 
the leg in a rigid position, and then use their arms to elevate 
themselves to the next step. 

Still another exercise is to place the patient in front of an arm- 
chair and teach him to lower himself into the chair without touching 
the arms of the chair with the hands. 

It is vitally important that these exercises shall not be continued 
until the patient is unduly fatigued. He should simply be slightly 
tired at the most, and usually a quarter of an hour, twice or thrice 
a day, is a sufficient length of time for the treatment. Exhaustion 
is distinctly harmful under these circumstances. The patient should 
be urged to respond promptly to directions, as alacrity is important 
in training the coordinate faculties. 

Somewhat similar exercises may be devised for the arms in cases 
where the upper limbs are ataxic as well as the lower ones. 



C0UNTERIRRITAT10N 



577 



COUNTERIRRITATION. 

Coimterirritation is a term ap- 
plied to the use of substances irri- 
tating to the surface with which 
they come in contact, and is em- 
ployed for the purpose of influen- 
cing morbid processes in more or 
less distant parts or of affecting 
the general system. It has been 
thought that this method savors 
of the doctrine of "like cures 
like," but in reality it is based on 
sound physiological laws. 

The entire basis for the em- 
ployment of counterirritation 
rests upon reflex action, or the 
conduction of a nervous impulse 
to a center, which, when so stim- 
ulated, sends out an impulse to 
the part of one body which is 
diseased. 

The use of counterirritation 
may be divided into four parts 
or purposes : the first is for affec- 
ting inflammations or congestions ; 
the second, for causing the ab- 
sorption or removal of inflam- 
matory deposits after true inflam- 
mation has ceased; the third 
purpose is for the relief of pain; 
and the fourth for the effect 
which can be exercised upon the 
general system by blisters in sys- 
temic disease. 

In the same manner that we 
divide the indications for counter- 
irritation into four parts, so can 
we also divide its forms into three 
varieties according to their sever- 
ity. The most severe are the 
caustics or escharotics, the next 
the epispastics or blisters, and 
finally the rubefacients or red- 
deners. 

The proper manner of employ- 
ing a counterirritant to affect in- 
flammation is not to apply it 
directly to an actually inflamed 
37 




Fig. 84. — To illustrate the nervous 
pathways by which are exercised the 
effects of counterirritation. Diagram 
giving a schematic representation of the 
course of the autonomic (sympathetic) 
fibers arising from the thoracico-lumbar 
and sacral regions of the cord. The pre- 
ganglionic fiber is represented in dotted 
lines, the post-ganglionic in solid lines. 
The arrows indicate the normal direc- 
tion of the nerve impulses or nerve 
conduction. S.c, superior cervical 
ganglion; I.e., inferior cervical gang- 
lion; T, the first thoracic ganglion; Sp., 
the splanchnic nerve; C, the semilunar 
or celiac ganglion; m, the inferior mesen- 
teric ganglion; h, the hypogastric nerves; 
N. E., the nervus erigens. The num- 
erals indicate the corresponding spinal 
nerves. (Howell's Physiology.) 



578 



REMEDIAL MEASURES OTHER THAN DRUGS 



area, but a little to one side of it, or at a spot known to be connected 
intimately with the diseased area by nerve fibers. 

Thus, it is well known that in diseases of the eye the blister should 
be applied back of the ear, and that in abdominal neuralgia or in 
pleurodynia the best results are reached, not from the application of 
a blister to the spot where the pain is felt, but to the point upon the 
vertebral column where the nerve at fault takes its exit. The reason 
for this is that pain is always referred to the peripheral end of an 




Fig. 85.— Showing the areas in which blisters are to be placed: P, pericarditis; 
A, appendicitis; L, laryngitis; V, vomiting or gastritis; P L, pleuritis; R, inflammation 
in joint. 



irritated nerve, and pleurodynia or abdominal pain often arises from 
vertebral disease or inflammation about the spinal ligaments or the 
foramina of exit for the nerves. In a similar manner a blister is some- 
times applied in the early stages of hip disease, not to the knee or 
ankle, where the pain is felt, but at the seat of the trouble— namely, 
the hip. Counterirritation is contraindicated by the presence of 
any acute inflammation directly under the spot where it is proposed 
to place a blister; that is, if any reddening of the skin is present, the 



CO UN TERIRRITA TION 579 

blister or other form of irritation must not be applied there. If 
used at all, it must be some little distance away, or a series of small 
flying blisters should be placed around the inflamed zone. Flying 
blisters are small in area — say as large as a Lima bean— and of com- 
paratively slight action, the blisters healing rapidly after their primary 
effects have passed by. 

Among the inflammatory infections in which counterirritation has 
been found very serviceable may be mentioned pleurisy, pneumonia, 
iritis, and synovitis (rheumatic or traumatic). A host of more sub- 
acute or chronic inflammations are also benefited by this measure, 
some of which are chronically enlarged joints and inflamed glands. 
In all these states the blister or, more rarely, a rubefacient is to be 
resorted to; and while it is true that many of these conditions are 
accompanied by fever, and that fever is generally held to be a con- 
traindication to the use of a counterirritation, blisters undoubtedly 
do good in some states. In pneumonia or pleurisy, in the very earliest 
stages of the disease, a cantharidal blister of the size of a silver dollar 
may be applied near the spot where the pain is most felt or on the 
back near the spine (Fig. 86). When a joint is inflamed, the blisters 
should be at some distance from the seat of the swelling, although it 
is often useful to place the counterirritant on the inner or outer 
aspect of the knee-joint if the skin is not reddened. 

Where an inflammatory process is chronic and resists cantharidal 
blistering, then resort is often had to more severe forms of counter- 
irritation by means of the red-hot— not white-hot — iron, or the use 
of escharotics, such as caustic potash or caustic soda or arsenic. 
The reason for using these is that they all cause so much tissue- 
change in the part that the counterirritation is very prolonged. 
These radical measures are now rarely resorted to. 

For the removal of the products of inflammation resort is had to 
cantharidal blisters or drugs possessing powers as local irritants and 
at the same time as alteratives. Thus, in pleurisy with effusion it is 
very proper to employ a number of small blisters if the effusion has a 
tendency to remain unabsorbed, but if the pleural surface is covered 
with a fibrinous exudate the blister can do little good as far as the 
effusion is concerned until this is absorbed. Some have thought 
that the absorption which follows is due to the abstraction of serum 
which takes place in the bleb formed, but this is a mistaken idea, as 
one often sees an effusion absorbed which far exceeds in quantity the 
amount of liquid in the blister. Under these circumstances the spot 
for applying the blister is, as a rule, immediately under the arm, 
about two or three inches below the axilla. The blister, while it is 
useful in causing absorption in chronic effusions and deposits about 
joints, is not so good as are alterative irritants; for example, iodine, 
which in the form of a thorough application at one sitting until the 
skin is black— not yellow or red— is often of service. In very chronic 
cases iodine ointment, alone or with lard, may be rubbed into the 



580 



REMEDIAL MEASURES OTHER THAN DRUGS 



parts with advantage, care being taken to stop its use for a day or 
two as soon as the skin reddens. This same treatment is also useful 
in treating enlarged glands in the neck and elsewhere before pus 
forms. . The treatment of acute and chronic inflammatory processes 
by blisters is not as frequently resorted to at this time as it formerly 
was. 




Fig. 86. — Showing the areas in which blisters are to be placed: O, earache or vertigo ; 
M, meningeal inflammation or effusion at the base of the brain; H, hemoptysis; P L, 
pleuritis; 7, intercostal neuralgia; K S, renal or spinal irritation; R, rheumatism or 
inflammation in joint. 

Much difference of opinion exists as to the proper treatment of 
the blister formed by cantharides. Where the blisters are small— 
that is, the size of the tip of a finger— they may be allowed to break 
of themselves, and then be dressed with dry cotton; if they are large, 
the blebs should be punctured at their most dependent part with an 
antiseptic needle and dressed with dry absorbent cotton, as by so 
doing the new skin rapidly forms underneath and is soon able to 



COUNTERIRRITATION 581 

carry on its normal functions. The proper treatment of the blister 
while it is forming is to apply a poultice, which will decrease the 
pain and aid in the formation of the bleb. 

One of the best treatments for epididymitis is to paint the scrotum 
black with many coatings of a strong solution of silver nitrate or 
tincture of iodine, to insist on absolute rest in bed, and to resort 
to the local use of cold. The testicles should also be supported by 
a suspensory or adhesive strips during this treatment, and aconite 
given if fever is present. 

For the relief of pain resort is very commonly had to the rube- 
facients rather than epispastics, since the more moderate applica- 
tions are equally effective in most instances, and do not leave skin 
lesions behind to remind the patient of his illness. 

Every one who has had stomach-ache and remembers the relief 
obtained by the use of a mustard plaster or spice plaster recognizes 
the value of this means of obtaining relief, and headaches are often 
amenable to similar treatment. These headaches may be neuralgic 
or due to dyspepsia or to cerebral anemia or congestion, but counter- 
irritation will nevertheless do good. A mustard or capsicum plaster 
may be applied to the forehead or to the nape of the neck. If neu- 
ralgic, a little menthol or oil of peppermint may be applied over the 
course of the nerve, which application, if it be supraorbital, will 
require care lest the oil gain access to the eye. 

For the treatment of pain in the belly or chest or elsewhere we have 
four means of producing counterirritation in the shape of rubefacients : 
the first is mustard; the second, capsicum; the third, the turpentine 
stupe; and fourth, the spice poultice. 

The mustard plaster should be made by mixing mustard flour with 
warm vinegar or water, and adding varying proportions of ordinary 
flour to modify its action. If the skin is tough, half mustard and 
half wheat flour may be employed; or, if a child is to be treated, the 
proportion should be only one-fourth mustard. The plaster is made 
by placing a piece of stout paper on a table and putting over it a piece 
of heavy muslin or linen. On this is smeared the mustard mass, and 
over this is placed a piece of thin linen, which prevents the poultice 
from adhering to the skin and modifies the burning according to its 
density. By folding the edges of the paper so that it resembles a 
picture-frame we have at hand a cheap, effective, and strong plaster, 
the back of which is supported by the paper. 

The spice plaster is made by mixing equal parts of allspice, cloves, 
cinnamon, and nutmegs, and adding thereto one-half part of black 
pepper. These constituents are made into a homogeneous mass by 
using a knife-blade to mix them, and are then sewed in a bag which 
is quilted to prevent sagging of the contents. One side of the poultice 
is now wetted with warm brandy, whisky, or vinegar and applied 
to the part desired. If the skin is tender, the proportions of pepper 
and cloves should be decreased. This plaster may be allowed to 



582 REMEDIAL MEASURES OTHER THAN DRUGS 

remain over the affected part for hours or even days, and is very 
useful in the treatment of gastric catarrh and indigestion, particularly 
those forms occurring in children. 

The turpentine stupe (see Turpentine) is not to be allowed to 
remain very long on the skin, as it may blister a tender cuticle, and 
the capsicum plaster may be so active as to produce unbearable pain. 

The proper way of treating all such burns from counterirritation 
is to apply simple cerate, petrolatum, or sweet oil, to which may be 
added carbolic acid in the proportion of 1 : 100. The carbolic acid 
acts not only as an antiseptic, but also as a local anesthetic, while 
the oil serves as a protective from contact with the air. 



CUPPING. 

Cups are used in two forms, the dry cups and the wet cups. The 
first depend almost entirely upon their counterirritant effect for their 
therapeutic value. A hollow glass bulb fitted with a valve or stop- 




Fig. 87. — Dry cups applied to the chest, as in a case of pulmonary edema, the early 
stages of pneumonia, or diffuse bronchitis. 

cock is placed upon the skin and exhausted by means of a small hand 
pump. The stopcock is turned to prevent the entrance of air and 
the cup allowed to remain until sufficient air leaks into it to overcome 
the vacuum and let it fall off. Several such cups placed over the 
bases of the lungs or kidneys relieve congestion and stasis in these 
organs. Dry cups are often employed, and are valuable aids in 
treating the conditions named. Dry cups are not to be used in acute 
pleurisy or peritonitis lest they injure the parietal serous membrane. 
A wet cup is applied as is the dry, but before it is placed on the 
skin the cuticle is incised by a scalpel in several places so that it will 
bleed freely when suction is produced in the cup. It is, therefore, 
both counterirritant and depletant, and is not to be used in feeble 
persons who cannot stand loss of blood. 



DISINFECTION 583 



DISINFECTION. 

Before discussing the subject of disinfection, attention must be 
directed to what is meant by the terms employed when speaking of 
this subject. At present we recognize that the word "germicide" 
is applicable solely to agents capable of killing the lower forms of 
life, whereas "antiseptics" are substances which render material 
with which they come in contact so antagonistic or unsuited to germ- 
development as to render it impossible, at least in an active state. 
To use a simile : the killing of the inhabitants of a district by shoot- 
ing them would stop all growth and be germicidal, whereas the 
destruction of the crops in those same parts would only be antiseptic; 
or, in other words, the people might remain, but would starve to 
death. (See article on Antiseptics.) 

We speak of germicides as disinfectants, but never of antiseptics 
as disinfectants if we use these terms correctly, but "germicide" 
and "disinfectant" are synonymous words. 

From what has just been said, it is evident that when dealing with 
filth we should always resort to disinfectants rather than antiseptics, 
for although the latter are good, the former are better. 

We have three ways of destroying germs which are particularly 
useful: The first is the total destruction not only of the germs, but 
also of their resting-place, by means of fire, which may be used in 
the case of old furniture, mattresses, and similar materials, and which 
may be extended to everything which has been about the patient if 
it is necessary to stamp out a brisk epidemic before it can get well 
under way; the second is the use of moist heat in the form of super- 
heated steam, or, better still for common purposes, the use of boiling 
water; and, thirdly, by means of disinfectant materials which have a 
proved reliability. 

Moist heat in the form of superheated steam is infinitely preferable 
to dry heat, but as superheated steam cannot be readily obtained, 
physicians usually direct clothing to be boiled for at least two hours. 

Very often the bed-clothes are taken from a sick-room, trailed 
through the house, and finally deposited at any spot until a con- 
venient time for boiling them occurs. This is radically wrong and 
capable of causing a widespread distribution of the disease. In all 
such cases the bed-clothes should be rolled off the bed in a bundle 
and completely submerged in a bucket or tub of boiling water, or, 
better still, in a corrosive sublimate solution of the strength of 1 : 1000, 
before they are taken from the room. This tub is now to be carried 
at once to the fire, and the clothes lifted out dripping wet and plunged 
into a clothes-boiler in which the water is actively boiling. The lid 
of the boiler is at once to be put on to increase the heat and prevent 
the escape of any germs in the steam or in the hot air which arises 
from the surface of the water. The active boiling should be con- 



584 REMEDIAL MEASURES OTHER THAN DRUGS 

tinued for one or two hours, and water be continually added to 
prevent scorching the contents of the boiler. 

It is important that food be not cooked on the stove at the time 
the clothes are being boiled, and no food should be in the room. 

If boiling cannot be resorted to for any reason, the clothes may be 
soaked in a 1 : 500 solution of corrosive sublimate, or formaldehyde 
solution, although neither of these is so sure a method of disinfection 
as boiling. 

The care of a room after it has been occupied by a case of infec- 
tious disease is of great importance, and is generally sadly misman- 
aged. Disinfection is best accomplished by formaldehyde gas, which 
may be set free in one of two ways : namely, boiling the official solu- 
tion by means of an alcohol lamp or other source of heat, whereby the 
gas is set free, or by the addition of permanganate of potassium to 
the official solution. The latter is a more expensive, but safer method, 
as it avoids the danger of fire in the tightly closed room. To satis- 
factorily disinfect a room containing 1600 cubic feet, 240 grams of 
potassium permanganate are placed in a large pail and 1 pint (500 
cc) of the official formaldehyde solution is poured upon it. This 
instantly results in a furious ebullition, which may cause the contents 
of the bucket, unless it is a very large one, to overflow. The volume 
of gas set free is so great that before the mixture is made the physician 
should have everything prepared so that he can at once leave the 
room. (See Formaldehyde.) The gas does not injure dyed stuffs. 

When formaldehyde is used, the following rules should be followed : 

1. All openings in the plaster or in the floor, or about the doors 
and windows, should be caulked tight with cotton or with strips of 
cloth or paper. 

2. The linen, quilts, blankets, carpets, etc., should be stretched 
out on a line, in order to expose as much surface to the disinfectant 
as possible. They should not be thrown into a heap. Books should 
be suspended by their covers, so that the leaves are separated and 
freely exposed. 

3. The walls and floor of the room and the articles contained in it 
should be thoroughly sprayed with water. If masses of matter or 
sputum are dried on the floor, they should be soaked with water and 
loosened. No vessel of water, however, should be allowed to remain 
in the room, as it will absorb the gas. 

4. One hundred and fifty cc (5 ounces) of the commercial 40 
per cent, solution of formaldehyde for each 1000 cubic feet of space 
should be placed in the generating apparatus. 

5. The room thus treated should remain closed for at least ten 
hours. If there is much leakage of gas into the surrounding rooms, a 
second or third introduction of formaldehyde at intervals of two or 
three hours should be made. 

As an additional measure of disinfection all movable objects are 
to be taken out of doors into the fresh air, and then the floor, sills, 



DISINFECTION 585 

and casings, are scrubbed with hot water, and soap. The water 
remaining in the bucket should afterward be boiled to kill the germs 
which may be in it. This scrubbing being accomplished, the same 
surfaces should be scrubbed a second time with a solution of corrosive 
sublimate (1:1000 or 1:500) and left wet, so that the mercury salt 
may remain on them. Cracks and crannies are to receive particular 
attention. After this is done the floor should be flushed with a 
solution of formaldehyde. 

An essential disinfectant for all diseases is good ventilation. Not 
only should as much air as possible be allowed to enter the sick-room, 
but after the patient has vacated the premises the windows should 
remain open for weeks if possible. Fresh air dilutes germs as fresh 
water dissolves or dilutes dirt. 

The question as to which are the best disinfectant substances is 
one that has attracted the attention of physicians and original 
investigators for years. The result of a vast amount of study and 
experience shows that formaldehyde in solution or in the form of 
gas is the best of all disinfectants (see also Formaldehyde, Part 
II), and that next to formaldehyde in value is corrosive sublimate 
in the proportion of 1 : 250 to 1 : 500, or even weaker, but that for 
cheapness, activity and general usefulness chlorinated lime is better 
still. The disadvantages in the use of corrosive sublimate lie in 
its ready decomposition, its formation of an inert albuminate of 
mercury when albumin is present, its inertness where lead pipes are 
present, and, above all, its expense. Chlorinated lime depends 
almost entirely upon its chlorine for any disinfectant power which it 
may possess. Chlorine gas itself is not readily handled, but the lime 
enables us to put it where we will. It cannot be employed to disin- 
fect colored .fabrics, as it bleaches them. None of these objections 
hold good against formaldehyde. 

Whenever chlorinated lime is bought, the physician should see that 
all the chlorine has not departed from it, as much of the material kept 
in the stores is so old as to be almost worthless. 

For scrubbing floors, chlorinated lime may be made into a solu- 
tion by adding a cupful to a bucket of water, and in privies it may be 
spread thickly over the surface of the mass of filth. 

It is useless to place chlorinated lime in saucers around a room 
for the purpose of disinfecting the air, as the amount of chlorine to 
the volume of air to be disinfected is as nothing. 

Copperas, or sulphate of iron, while largely used as a disinfectant 
is in reality only an antiseptic. 

Disinfection of the discharges of the patient suffering from an 
infectious disease is an important duty to be remembered. The urine 
and feces should always be received in a vessel containing enough 
corrosive sublimate solution (1:500) to kill all germs,' and to prevent 
their escape into the air or into water or food when the discharges 
are thrown away. The disinfectant should be placed in the bed-pan 
before, not after, it is used. Masses of feces should be broken up. 



586 REMEDIAL MEASURES OTHER THAN DRUGS 

The bed-pan or chamber should not be allowed to stand in the 
room, but be removed and emptied at once in such a manner that its 
contents cannot contaminate any water or food. Its contents should 
not be thrown upon the ground, as the air will dry them and cause 
the germs to be disseminated in the form of dust. 

In very contagious diseases bathing or swabbing off the patient 
with weak antiseptics may be tried. Thus 1:10,000 solution of 
bichloride of mercury may be used and the patient afterward wiped 
off with a wet towel. In other instances a 1:500 solution of car- 
bolic acid in sweet oil may be employed to soften the skin, allay 
itching, and disinfect the patient. This is particularly useful in 
scarlet fever. 

ENTEROCLYSIS. 

Enteroclysis, or the washing out of the bowel by means of large 
and slowly injected clysters for the purpose of medicating or cleansing 
the large intestine, has become one of the most valuable therapeutic 
measures we possess. It is of value not only for the purposes named, 
but also for the relief of intestinal obstruction, for the maintenance 
of body heat by the use of hot water, and for the reduction of fever 
by the use of cold water. 

The employment of irrigation of the colon in cases of dysentery is 
by no means of recent date. It is only, however, within the last 
few years that this method of treatment has been widely employed 
or studied. Aside from the fact that by this means we can bring 
medicaments in direct contact with the diseased mucous membrane, 
there is no doubt whatever that the mere passage of normal salt 
solution at suitable temperatures over the bowel-wall is of value, for 
in this manner we remove mucus and pus, and so dilute the poisons 
produced by the germs of the disease that their further action is 
largely inhibited. In adults the use of irrigation in dysentery 
should be carefully carried out by means of an inflow and an outflow 
tube, the first being attached to fountain-syringe. The outflow 
tube must be large enough to permit of the liquid leaving the bowel 
with a readiness equal to that of its inflow, and must be so straight 
and patulous as to permit of the fluid carrying away with it from 
the bowel any flakes of mucus or other foreign matter. The inflow 
tube should be introduced a considerable distance into the bowel 
and the outflow tube placed just within the sphincter. The method 
employed in giving the injection, the temperature of the water, and 
the gentleness of the operation are exceedingly important, and will 
be discussed below. The amount of water employed in irrigation 
of the bowel in dysentery is not to be measured by quarts, but by 
results. It should continue to flow in until it comes from the out- 
flow tube perfectly clear, showing that our object— namely, thorough 
cleansing of the bowel— has been accomplished. The best medi- 
cament to be added to the water is boric acid or tannic acid, each 



ENTEROCLYSIS 587 

of which is harmless and capable of doing much good. In nearly 
all instances in which we -wish to cleanse the bowel a normal salt 
solution should be employed rather than pure water, as the latter 
tends to irritate the intestinal wall. (See Ipecac and Cinchona.) 

The question as to what is the best method of treating a case of 
intestinal obstruction by enteroclysis is one which is of interest to 
the physician as well as the surgeon. Such cases generally come 
into the hands of the general practitioner first, and it is for him to 
decide whether the surgeon shall be called in consultation. The 
author is not one of those who place much confidence in the reports 
of cases of volvulus or intussusception overcome by enteroclysis. 
The true indication for rectal injections is obstruction due to impacted 
feces. 

A very important point to be decided in connection with this 
subject is the amount of pressure that can be used with the stream 
of water which is employed, the length of time during which the 
injection may be given, and, finally, the temperature and character 
of the fluid injected. As is well known, the great majority of cases 
of intussusception take place at the ileocecal valve, and, if not here, 
in the sigmoid flexure. Pressure by injection is therefore readily 
brought to bear on the area involved. It has been claimed that 
certain pressures will cause rupture of the peritoneal coat of the 
intestine, but Dr. Martin and the writer failed to produce this 
lesion in the dog by any pressure we could employ, since before 
this occurred the liquid passed through the stomach and mouth. 
To employ a pressure exceeding eight pounds is, however, distinctly 
dangerous, not because the intestinal wall in health will not stand 
this as a rule, but because it is near the injury line, and if any disease 
or softening of the bowel exist, it is almost certain to cause rupture. 
A pressure of from two to five pounds is, as a rule, as much as may 
be employed, and this pressure should be reached by degrees, start- 
ing the injection at such a pressure that the flow amounts to hardly 
more than trickle, and increasing the pressure as the antagonism of 
the bowel is overcome. Finally, when the bowel is fully distended 
up to the point of obstruction, the pressure on the no longer moving 
column of water may be increased, if necessary, to six or eight pounds 
by raising the bag of water not more than three feet. In infants, in 
whom invagination so often occurs, a pressure greater than two 
pounds is dangerous, and it is of vital importance that the pressure 
be employed properly, otherwise it will do more harm than good in 
several ways. As a rule, in our anxiety to give the patient relief 
at once we are inclined to use too much force and too large a bulk 
of water, and think that active force, if such a term may be used, 
is to be resorted to. Those who have seen these cases have learned 
by experience the harmfulness of such measures, and have also 
learned how great is the expulsive power of the bowel when it is 
excited to contraction. If this power be brought into activity, it 
will be almost impossible to inject fluid into the rectum. 



588 REMEDIAL MEASURES OTHER THAN DRUGS 

The dangerous practice of using a Davidson or any other kind of 
hand force syringe in the treatment of this class of cases is to be 
condemned. Several unreported cases of tupture of the bowel and 
death from the employment of the Davidson syringe for this purpose 
have occurred, because the amount of force used was indeterminable, 
and because the fluid was injected with a jerking instead of a con- 
stant flow. The amount of fluid injected should be large, and if it 
is impossible to get a large amount into the bowel, it is probably 
because the inflow has been so rapid as to excite intestinal opposition 
or the rectal tube is plugged by hardened feces or kinked. 

Finally, the author cannot leave this subject with saying a word 
concerning the temperature of the injected liquid and its consti- 
tution. An injection of this kind goes into the very heat-citadel of 
the body, and if too cold, as it often is, produces dangerous chilling 
of organs which are ordinarily especially protected from cold by 
the omental apron and intestines. By repeated experiments, 
Martin and the author found that water at 65° F. lowered the bodily 
heat three degrees in thirty minutes. The use of colder water than 
this (52° F.) resulted in death in twelve hours, and the post-mortem 
showed intense congestion of the colon, which contained bloody 
mucus. 

The use of water of too high. a temperature is also dangerous, 
lest it produce heat-stroke. Of course no one would use water hot 
enough to produce local harm, yet it is necessary to have just enough 
heat and no more. Martin and the author proved that the use 
of water at 115° F. caused in twenty-five minutes a rise of bodily 
temperature in the axilla of nearly iive degrees, and developed 
marked symptoms of heat-dyspnea. The temperature which it is 
right to employ we found to be 101° to 103° F. as the water entered 
the bowel, or even as high as 104° F. in the water-bag if a long tube 
were used, as under these circumstances the water is rapidly cooled. 
An interesting result of these experiments as to heat is that when 
cold water was used it took four times as long to make the injection 
as when moderately warm water was employed. 

If very large injections are used, a normal saline solution of 7 : 1000 
(1 dram to 1 pint) should be employed to avoid the abstraction of 
vital salts from the intestinal wall, with consequent passage of 
water into the tissues, making them boggy, due to the law of osmosis. 
If the saline solution is stronger than 0.9 per cent., it abstracts water 
from the bowel wall and causes irritation and thirst. Distention of 
the bowel by injection produces little if any effect on the circulation 
and respiration, but the passage of large amounts of warmed fluid 
directly into the closed abdominal cavity causes death rapidly. 

Rectal injections of hypotonic salt solution in the strength of 0.5 
per cent, are very useful to relieve thirst and to keep the kidneys 
active after abdominal operations and during the course of acute 
infectious diseases when there is scanty flow of urine and marked 



GAY AGE 



589 



toxemia. (For the Murphy Drip or Proctoclysis see article on 
Peritonitis, Part IV; Nutrient Injections see Levulose, Part I; 
Feeding the Sick, Part III, and Diabetes Mellitus, Part IV.) 



GAVAGE. 

Gavage is a term applied to the forced feeding of patients who 
will not or cannot swallow food. The method is often employed 
in nourishing the insane who refuse food (Fig. 88). A soft-rubber 



1 




1 




| 


f 


Jj 


t 




J* 





Fig. 



-Showing the introduction of a soft catheter through the right side of the 
nose in the practice of gavage. 



catheter is passed through one of the nasal chambers back into 
the pharynx, a small funnel is attached to its outer extremity, and 
the milk, or beef-broth, or other liquid food is by this means intro- 
duced into the pharynx, where the muscles of deglutition seize it. 
The term gavage is also correctly applied to the forced feeding of 
a patient by an esophageal tube, as in the use of lavage. (See 
Lavage.) 



590 REMEDIAL MEASURES OTHER THAN DRUGS 

HEAT. 

Heat is used locally for a number of purposes in the same manner 
as is cold, and, as was stated in the article on Cold, the choice of 
heat or cold in the treatment of any acute form of inflammation 
depends almost entirely upon the wish of the patient, who generally 
can tell at once which will give him the greater comfort. 

In sprains of the ankle nothing compares to a hot foot-bath pro- 
longed for hours, the object being to decrease the pain and swelling, 
thereby regaining the use of the limb. The high degree of heat which 
can be borne by gradually increasing the temperature of the water 
by the addition of small quantities of scalding water is extraordinary, 
and the favorable results obtained are in direct ratio to the height 
of the temperature. Between these soakings the part should be 
dressed with lead-water and laudanum, and rubbed with ichthyol 
ointment or camphor liniment and laudanum. 

In spasmodic affections involving either striped or unstriped 
muscular fiber the local application of heat is a very useful means 
of relief. Sometimes in lumbago, or muscular stiffness in other 
parts of the body, the use of an ordinary hot laundry iron over 
the affected parts will prove of great service, the skin being covered 
by several layers of newspaper to afford a smooth surface over 
which to pass the iron and to protect the parts from too great heat. 

In chordee the best means for rapid relief, other than the use of 
drugs or general relaxants, such as amyl nitrite, is to steep the penis 
in hot water. A hot sitz-bath before going to bed is a good pro- 
phylactic against this painful complication of gonorrhea. 

In croup of the spasmodic type the local application of a hot 
compress, made by wetting a stocking with hot water, is very useful, 
or several layers of flannel should be wetted, placed on the throat, and 
covered with wool and oiled silk so as to prevent the roll becoming 
chilled. 

Nearly all forms of pain in the eyes can be much relieved by the 
application of heat. Thus iritis, corneal irritation and ulceration, 
and pain due to eye-strain can be greatly relieved by the use of 
hot water applied by cotton pledgets frequently renewed, but never 
allowed to remain on long enough to act as warm poultices. Another 
method is to allow water as hot as can be borne to drop upon the 
lids from a fountain-syringe. The water-bag should not be more 
than two feet above the patient's head, and the fluid should drop 
on the eyelid from the distance of a few inches only. 

Where attacks of dysmenorrhea depend upon spasmodic closure 
of the cervix, with simultaneous spasm of the fundus uteri, a hot 
sitz-bath or hot vaginal injection is useful, and this treatment is 
also of value where uterine congestion results in leucorrhea or a 
sensation of weight in the pelvis. 

Sometimes attacks of torticollis may be subdued by applying 
hot compresses to the sternocleidomastoid muscle. 



HEAT 591 

The local application of heat may serve to determine whether the 
inflammatory process has gone on to the formation of pus. Before 
pus is formed heat decreases the pain, it is claimed by Lewin, but 
afterward greatly increases it. 

Heat is largely used, when the skin or kidneys are torpid, to aid 
in the elimination of impure and effete materials from the blood 
and tissues. It is employed in two forms, the dry and the moist, 
commonly called the Turkish and Russian baths respectively, and 
may be taken under home arrangements or in one of the establish- 
ments found in all large cities. 

The Turkish bath consists of a series of rooms ranging in tem- 
perature from 100° to 150° F. or more, into which the individual 
passes successively until the hottest room is reached. In each 
chamber he lingers until the system becomes accustomed to the 
high temperature, and perspiration is well established before he 
enters the hottest room, where he remains for a varying length of 
time according to the advice of his physician or his own whim or 
comfort. The rule governing his stay is that he must leave it at 
once if any sense of oppression is experienced or if perspiration does 
not flow freely. Sometimes a glass of cold water taken at this time 
causes a sudden profuse sweat, and also relieves any overheating 
by abstracting many units of heat. The cold water in the center 
of the body causes contraction of the bloodvessels in these parts, 
and the blood, rushing to the surface, causes the sweat-glands to 
pour out their secretion. 

Following the stay in the warm room, the individual passes into 
still another chamber, where he is shampooed from head to foot, 
well rubbed, and the blood made to circulate through the skin. 
The shower-bath is then used, at first hot or warm, and finally 
changed to a dash of cold, or, the patient plunges into a long tank, 
swims to the other side, and is there met by an attendant who 
rapidly dries his skin, wraps a cover around him, and shows him to 
a lounge, where he is supposed to sleep for an hour or so. The air 
of this sleeping-room is at the ordinary temperature of a living-room. 

Reviewing for a moment the effects of this bath, we find that 
the first two-thirds are devoted to the opening and stimulation of 
the pores of the skin, while the last third is devoted to the contrac- 
tion of these pores and their supplying bloodvessels. In other 
words, it is necessary to use the cold to prevent gradual chilling, 
which would result in internal congestion. If the patient receives 
a cold douche, the natural rebound prevents congestion of a per- 
manent nature, whereas if he is exposed to cold a long time, these 
stagnated areas become permanently diseased. The physician must 
always remember that this cold douche or plunge is a sine qua non, 
and that a rest after the bath before dressing is almost equally 
important. If the patient is too weak to bear the cold, it may be 
supplanted by an alcohol rub. 

The indications for the Turkish bath as a medicinal measure in 



592 REMEDIAL MEASURES OTHER THAN DRUGS 

any condition of the emunctories of the body whereby effete matters 
are not properly eliminated, as in Bright' s disease in its various 
forms. The increased action of the skin not only casts off impuri- 
ties for the time being, but frequent repetition of the bath causes 
functional hypertrophy of the sweat-glands, and eventually enables 
them to do more work, or, in other words, to cast off an increased 
quantity of effete material. As a consequence of this the patient 
is able to decrease the tendency to uremia or other evidences of 
Bright's disease, and, employing the normal epithelium still left 
in the kidney for constant use, uses the bath once, twice, or thrice 
a week with the object of abstracting the excess of impurities which 
the impaired kidneys cannot remove. The frequency of the bath 
depends, therefore, upon the rapidity with which the effete materials 
accumulate. In a case of Bright's disease the patient should not 
attempt to use the room containing high heat at first, and should be 
accompanied by a medical attendant to watch for untoward effects, 
particularly if the heart is diseased or uremia is already shown by 
headache or other signs. If sweating does not come on at once, 
danger is at hand from acute uremia, renal and cerebral congestion, 
or heat-stroke. 

Not only is the Turkish bath useful for kidney disease, but it is 
often of great service in rheumatism. The acute forms of rheuma- 
tism is never so treated, because cardiac complications forbid expos- 
ure to heat, and fever is generally present. In subacute and chronic 
rheumatism the case is different, and the enlarged joints or inflamed 
muscles greatly improve in some instances from such treatment. 
Further than this, the muscular stiffness following prolonged or 
severe effort can be so avoided, and neuralgia depending upon rheu- 
matic or gouty taint may be relieved by the hot-air bath. 

Acute colds affecting the nasal cavities or other parts of the body, 
at an early formative stage, can often be aborted by a thorough 
Turkish bath, and when further developed are often greatly relieved 
by the same means. If, however, congestion of the lung, pneumonia, 
or chronic bronchitis, with emphysema or a dilated weak heart, is 
present, the bath may be dangerous. In acute pharyngitis, in which 
the pharynx feels like a raw surface or " as if it were filed or scraped," 
the bath will give relief in many instances. 

Sometimes in suppression of menstruation from cold the flow may 
be restored by a Turkish bath. 

Some persons complain that they are always catching cold upon 
the slightest exposure and apparently without cause. One class 
seem to have delicate mucous membranes readily susceptible to 
irritation and inflammation; the other have dilated or relaxed peri- 
pheral capillaries, which readily allow the blood in them to become 
chilled, and the individual consequently suffers from internal local 
congestions. Two separate means of treating such cases exist: 
The first class will do well on minute doses of arsenic trioxide (grain 
t ^q to ^0") three times a day, used for weeks; the second will be cured 



HEAT 593 

of their habit by the use of a Turkish bath twice or thrice a week, 
since by this means the peripheral capillaries are toned up and 
made more active. 

The Turkish bath, as thoroughly carried out in large cities, is not 
obtainable for those living elsewhere, so it is well to describe a home 
modification which, with attention to detail and care, may prove 
almost; if not quite, as effective a remedy. (See Figs. 89 and 92.) 

The patient is placed upon a wooden chair, naked, and under 
the chair a small alcohol lamp is put, which is lighted. The indi- 
vidual is now wrapped thoroughly, chair and all, w r ith one or two 
large blankets, when the heat of the lamp soon causes profuse sweat- 
ing. Many cases are, however, on record where the lamp has been 
upset and the patient badly burned. The best way is to have the 




Fig. 89. — A method of giving a bedridden patient a hot-air bath where a sweat is 
desirable, or where shock with a collapse temperature is to be controlled. The bed- 
clothing is raised by a cradle. An alcohol lamp is placed under the inverted funnel, 
and the hot moist air is carried in this way to the patient without any danger of fire 
or burning the skin by hot bottles. 

lamp a little to one side and its flame immediately under the mouth . 
of an inverted funnel attached to a piece of tin tubing, the free 
end of which is placed under the blanket, so that the hot air and 
vapor may surround the body. If the tube be covered with cloth, 
the loss of heat is slight and the danger of burning the patient is 
removed. If this is not practicable, several very hot bricks or 
stones, thoroughly heated in an oven, may be placed under the 
chair, or small heated logs of wood may be substituted. 

When the patient is too feeble to sit in a chair, then it is wise to 
place an alcohol lamp at the foot of the bed, with an inverted funnel 
attached to a tube which passes under the bed-clothing in such a 
way as not to bring the hot air directly against the skin of the patient. 
The bed-clothing may be slightly raised to allow the hot air to enter. 
The vapor of the alcohol lamp tends to sweat the patient. This 
38 



594 



REMEDIAL MEASURES OTHER THAN DRUGS 



is also a valuable mode of using external heat in cases of shock 
(Fig. 89). 

A modified form of Turkish bath, now commonly resorted to, is 
the electric cabinet bath. This consists of a box large enough for 




Fig. 90. — Electric light bath cabinet. 



the patient to sit in on a stool after he is stripped. His head pro- 
jects through a hole in the lid and a towel is placed around his neck 
to keep the hot air in the cabinet from escaping. The box being 
lined with 20 to 30 incandescent lamps when the electric current is 



HEAT 



595 



turned on they give off a great amount of heat so that within a 
few moments the temperature in the cabinet is 120° F. By reason 
of the stimulating effect of the light upon the skin the patient sweats 
as freely at 120° F. as he would in a Turkish bath at 130°, and there- 
fore is not exposed to very high oppressive heat. Furthermore his 
head is not heated, but kept cool by cloths wrung out in ice-water, 
and, as he does not inhale hot air, his lungs are not exposed to great 
change of temperature when he goes out of doors. This, he should 
not do, however, in any event before one or two hours. After being 
in the cabinet fifteen to twenty minutes he is found to be sweating 





h 





Fig. 91. 



-Nurses using two broom-sticks to wring out a blanket dipped in very hot 
water for use in the hot pack. (From the author's wards.) 



freely. He is then allowed to get out, is rubbed down with tepid 
water and soap, and finally with alcohol and water, and after this 
should lie down lightly covered and cool off gradually. Although he 
should be dried with a towel he should not be rubbed with it, as this 
again dilates the skin vessels and induces further sweating. When 
an electric cabinet is not obtainable, a folding frame covered with 
rubber sheeting may be obtained from any instrument maker and 
the heat supplied by an alcohol or other lamp or a Bunsen burner. 
A similar apparatus shaped so that it covers the patient when lying 
in bed can also be had for patients too weak to sit up. 



596 



REMEDIAL MEASURES OTHER THAX DRUGS 



The Russian bath differs from the Turkish in that the heat used 
is moist, not dry. As a consequence the danger of heat-stroke and 
similar states is much increased, because evaporation from the skin 
does not go on so rapidly and the body is not cooled so well. 

The hot moist bath can also be obtained by seating the patient on a 
wicker chair under which is placed a bucket of hot water. The patient 
is surrounded by a blanket, and a large hot iron or stone is put into 
the water, causing the development of a great amount of steam. 

This method of treatment is useful in the same states as is the 
Turkish bath, but is more rarely used. It may also be employed to 
develop the rash of any of the exanthema tous fevers when it is 
suppressed by cold or is not "well out" on the skin. 

Under the name of the "hot pack" still another substitute for 
the Turkish or Russian bath is used, not only to cause sweating and 
so relieve the patient of poisons in renal diseases, but also to relax 
muscle spasm and to relieve nervous excitement and nervous insomnia. 
It is particularly efficacious in the insomnia of severe chorea in 
children, and may be used in tetanus. 




Fig 



92. — Showing arrangement of blankets in giving a hot pack for uremia. 
(From the author's wards.) 



^Yhenever the Turkish or Russian bath or hot pack is used, except 
in the exanthematous fevers, it should be followed by a cool sponge, 
plunge, or douche. 

Although these baths have been used in the treatment of cases of 
heart disease to relieve dropsy and renal engorgement, they are not 
safe, and should not be generally employed. All acute or chronic 
diseases of the lung, except acute bronchitis of a mild form, contra- 
indicate their use. 

A bed is prepared by covering it with a rubber blanket. Over this 
is placed a dry woolen blanket. A large heavy blanket is now 
dipped in very hot water and then wrung out (Fig. 91), and the 
naked patient quickly wrapped in it, the dry blanket being folded 
over him after several hot-water bottles have been placed alongside 
the patient. Finally the sides of the rubber sheet are drawn around 



HEAT 



597 



and over the patient and an iee-cap placed' on the head (Fig. 92). 
A thermometer should be placed in the mouth every fifteen minutes, 
and if the patient's temperature becomes febrile (101° F.) he should 
be taken out of the blankets and rubbed dry. Ordinarily the bath 
should last about one hour, and if sweating does not speedily come 
on a glass of cold water should be taken to drive the blood to the 
skin. In adults a little gin may be added to it, or sweet spirit of 
nitre may be used in this way in children and adults. If no sweat 
develops and the temperature begins to rise, the patient must be 
taken out of the bath at once. The hot pack in uremia is contra- 
indicated if there is any tendency to pulmonary edema. 

The mustard hot pack is often useful in the treatment of internal 
congestions and particularly so in the bronchopneumonia of infants 
and children. It is to be employed as follows: 




Fig. 93. — Frazier-Lentz hot-air apparatus. 

Oil of mustard, 10 minims (0.65), is thoroughly mixed with a pint 
(500 cc) of alcohol and water in equal parts, the water being heated 
before the mixture is made. A large piece of flannel is saturated with 
this mixture and the child is wrapped in it from the neck to the feet, 
and then, in turn, wrapped in a thin blanket. After the lapse of ten 
to twenty minutes the skin will be found to be bright red, and the 
flannel is then taken off and the child wrapped in another piece of 
flannel which has been wrung out in a mixture of alcohol and warm 
water in the proportion of one to two parts. In this second wrapping 
the child lies for half an hour, after which it is again wrapped in a dry 
blanket or, if the weather is warm, in a dry sheet. The mild counter- 



598 



REMEDIAL MEASURES OTHER THAN DRUGS 



irritant effect of this application draws the blood from the congested 
lungs, and in the case of eruptive fevers, in which the eruption is not 
fully developed, it will frequently relieve nervous symptoms and 
develop a rash. If there is reason to believe that the child's skin is 
exceedingly sensitive, 5 minims (0.033) of the oil of mustard instead 
of 10 minims (0.65) should be employed. 

Another wet pack, which speedily becomes a warm one, is used in 
cases in which, during the course of an eruptive fever, the eruption fades 
and it is desired to bring it out on the surface. It is also useful in those 
cases of severe chorea in which the child can withstand the first shock 
of the cold. It consists in wrapping the child in a cool wet sheet 
and over this wrapping one or two blankets. In a few minutes the 
sheet becomes heated by the body and the sweating which results is 
profuse. 




Fig. 94. — The Newell hot-air apparatus. 



A valuable method for using moist heat in a mild form is the 
"bronchitis tent." (See article on Bronchitis.) 

The use of a high degree of dry heat for the cure of inflammatory 
states of the sheaths of the joints and muscles consists in the employ- 
ment of a double copper cylinder closed at one end, inside of which 
is placed the limb which is affected. The limb is prevented from 
coming in contact with the cylinder by means of a board padded 
with asbestos and by putting pads of linen under the parts which 
would touch the asbestos. A thermometer is placed so that its bulb 
extends into the cylinder, and a few holes permit of the moderate 
circulation of air. Bunsen burners or alcohol lamps are now lighted 
and placed under the cylinder, and the orifice through which the 
limb enters it is closed by drawing around the limb an asbestos 



HYPODERMOCLYSIS 599 

curtain. The temperature is allowed to rise to 200° to 300° F., 
and the treatment resorted to daily, or several times a week, the 
individual seance lasting about one hour. The free sweating of the 
limb and the circulation of the blood and lymph prevent it from being 
burnt, but care must be taken that it does not touch the metal. 
Usually the entire surface of the body sweats profusely during the 
sitting. ri 

The author believes this method to be of great value in cases of 
chronic inflammatory joint affections due to rheumatism or following 
injuries, but of little service in those due to gouty swelling. In sub- 
acute gout he has seen it precipitate an attack of universal acute gout, 
apparently by setting free large amounts of urates from the affected 
joints. 

This method of treatment is always to be considered as a valuable 
aid in the treatment of the more obstinate cases of the character 
described. The best form of this apparatus is expensive. A less 
expensive apparatus is shown in Fig. 94. 

HEMOSTATIC SERUM. 

Hemostatic serum or " hemoplastin/ is a sterile derivative from 
blood. It is used to control persistent hemorrhage from small 
vessels which cannot be occluded by ligation or compresses, as 
after operation in certain cases and in the hemorrhage of the new- 
born, and in hemophilia. In other words its particular field of use- 
fulness is in cases characterized by delayed coagulation. 

The principles involved in its action are as follows: The blood 
contains all the elements needful for coagulation (chiefly thrombin), 
but is prevented from clotting by the presence of antithrombin. If 
the blood escapes from its vessels it comes in contact with thrombo- 
kinase which is present in the tissues and probably in the white cells 
and blood-platelets, and this neutralizes the antithrombin. Howell, 
whose work on these lines is classical, places the process in this wise : 
Blood plus thrombokinase plus calcium produces thrombin which 
plus fibrinogen produces fibrin which in its meshes holds cells, so 
forming a complete clot. The dose of hemostatic serum is 1 cc 
to 2 cc given hypodermically or in urgent cases intravenously, the 
dose being repeated every few hours until the oozing ceases. It 
may also be applied locally on cotton whent he bleeding point can 
be reached. 

HYPODERMOCLYSIS. 

Hypodermoclysis is a method of supplying fluid to the body to 
replace that lost through excessive purging, as in cholera, or in cases 
of hemorrhage. Further, it may be used to wash from the body 
various impurities circulating in the blood and lymph, and to flush 
the kidneys. In other instances it may be used to supply the body 



600 REMEDIAL MEASURES OTHER THAN DRUGS 

with liquid when the stomach will not permit liquid to be swallowed, 
as in vomiting, or gastric ulcer or after abdominal operations. It 
consists in the introduction into the subcutaneous tissues of normal 
saline solution, which is rapidly absorbed by the vessels. As is well 
known, a quantity of liquid equal to four times that of the normal 
amount of blood may be passed directly into the veins without pro- 
ducing a rise of blood-pressure, and experiment has shown that usually 
within fifteen minutes after the fluid flows into the subcutaneous 
tissues an increased flow from the kidneys takes place. It is not safe 
to infuse a greater quantity of liquid than 1 dram to each pound of 
body-weight in each fifteen minutes, as, if this amount is exceeded, 
the accumulation of the liquid in the system is so great that the 
tissues become drowned, because the kidneys cannot excrete the 




Fig. 95. — The apparatus and method used in giving hypo dermocly sis. The ordi- 
nary irrigator is attached to a small cannula, and this is placed in the loose tissue of 
the belly-wall. 

liquid fast enough. To carry out the operation, the sterilized liquid 
to be infused— the formula on page 612 is the best— is placed in a 
glass irrigator jar or rubber bag, which is absolutely aseptic. From 
the lower part of the vessel leads a rubber tube to which is attached 
a large hollow needle, also rendered sterile. The skin over the place 
where the liquid is to enter is to be rendered absolutely sterile, the 
needle is then inserted into the subcutaneous tissue of the thigh, or, 
preferably, of the abdomen, or below the breast, and the liquid 
allowed to flow at a rate named, the pressure being obtained by raising 
the container two feet above the belly- wall (Fig. 95). As the liquid 
enters, a swelling appears in the subcutaneous tissues, which soon 
disappears after the infusion ceases, and is much aided in its absorp- 
tion by the use of very gentle rubbing or stroking. 



INHALATIONS 601 

When hypodermoclysis is employed after hemorrhage, the results 
are often extraordinary. It is of great value in the collapse of cholera. 
(See Cholera.) The cyanosis decreases rapidly, the pulse improves, 
and respiration is no longer difficult. Some physicians have used 
hypodermoclysis with very good results in the treatment of uremia 
due to chronic contracted kidney after venesection, thereby diluting 
the poisons and preventing them from acting so severely. In 
septicemia, diabetic coma, and similar states this method of treatment 
may be employed. When general dropsy is present, it is manifestly 
useless and harmful. Hypodermoclysis has also been used with great 
advantage in the treatment of severe burns to overcome shock and 
toxemia. 

In cases of surgical shock warm saline fluid used by hypodermoc- 
lysis is often of great service. (See also Intravenous Injection; 
Transfusion.) 

INHALATIONS. 

The value of inhalations is not recognized sufficiently by the medical 
profession. As a matter of fact, they are capable of aiding very 
much in the treatment of disease and of producing results otherwise 
unobtainable. The employment of inhalations may be divided into 
the properly modified use of atmospheric air and the employment of 
atmospheric air charged with medicinal subtances. To carry on 
many of the forms of treatment which have been found of value 
requires cumbersome or costly apparatus which cannot be used except 
in institutions; but nevertheless the general practitioner can employ 
remedial measures by way of the respiratory organs with great advan- 
tage to his patients even when far removed from places where costly 
apparatus can be had. 

The first form of inhalation to be studied is that which is devoted 
to proper respiratory exercises. These exercises are required by 
patients who because of faulty development do not properly expand 
certain portions of the chest in the function of respiration, and by 
those who have acquired impaired respiratory movements through the 
following of certain occupations or as the result of attacks of disease. 

There can be no doubt that pulmonary tuberculosis may be pre- 
vented, or even arrested in its earliest stages, by causing a patient to 
use proper thoracic exercises, which must usually be directed toward 
producing expansion of the apices of the lungs, a part of these organs 
which in many instances is but poorly filled and equally ineffectively 
emptied under ordinary conditions of life. On the other hand, if the 
tuberculous process is active such exercises are usually unwise. The 
following inhalation exercises are to be directed for early and mild 
cases : 

The patient stands with his back against a wall, holding himself 
as erect as possible and bringing his shoulder-blades flat against the 



602 REMEDIAL MEASURES OTHER THAN DRUGS 

plane behind him. He now takes a slow, deep, and full inspiration, 
drawing the air into the chest in a steady stream, and not by a sudden 
jerk of the respiratory muscles. The inspired air is to be held in 
the chest while the patient mentally counts three, and then allowed 
to escape gradually, and not forced out of the chest by sudden muscu- 
lar effort. Usually four or five such movements night and morning 
are quite sufficient for good results for the first week. After that time 
they may be gradually increased in number. 

Another movement may now be added to that just described. The 
patient, standing with his back against the wall and the shoulders 
well thrown back, raises his arms, which are completely extended from 
the sides until the hands are on a level with the shoulders, thereby 
fully expanding the sides of the chest. As expiration begins the arms 
are allowed to fall gradually to the sides. After this the arms may be 
carried above the head into a perpendicular position. 

A third exercise consists in inhaling as deeply as possible and then 
exhaling against resistance produced by closing the lips and forcing 
the air between them. 

The fourth exercise consists in lying upon a firm bed with a small 
pillow under the hollow of the back and no pillow under the head, and 
then taking slow, long-drawn inspirations and expirations as already 
described. 

These exercises are useful not only in persons with faulty chest 
development, but also in those who have poor expansion of a lung 
some weeks after a pneumonia, pleurisy, or empyema. 

The increase in the volume of air respired under gentle but per- 
sistently taken exercise of this character is quite remarkable and these 
movements often increase the appetite, the proportion of hemoglobin, 
and the general health of the patient. 

In addition to these exercises there are others which, while not 
directly connected with breathing produce, nervertheless, deeper 
respirations and at the same time develop the chest muscles and cause 
the patient to hold himself erect, thereby preventing or correcting 
faulty pulmonary expansion. Nearly every physician can look back 
upon cases in which a slovenly carriage of the shoulders in early life has 
resulted in impaired chest expansion and finally in actual disease. 
The exercises to be ordered are shown in Figs. 96 to 103. 

The next class of exercises consist in using simple forms of apparatus 
in association with respiratory movements. These are advantageous 
not only because they are beneficial in themselves, but also because 
they interest the patient and cause him to take exercises of which he 
might tire if they were performed without appliances. 

The first of these consists in a pair of Wolff bottles joined together 
by a piece of rubber tubing (Fig. 104) . The bottle nearest the patient 
is filled with water, and the patient, after taking a deep inspiration 
at the end of expiration, places a mouth-piece attached to a rubber 
tube between his lips and forces the water over from the first to the 



INHALATIONS 



603 



second bottle. This is usually sufficient for an exercise, and later in 
the day the patient drives the fluid from one bottle to the other a 
second time. Such a procedure causes the patient to take full inspira- 





Fig. 96. — Standing erect. 



Fig. 97. — Stretch standing. 





Fig. 98. — Wing standing, side bending. Fig. 99. — Wing standing, trunk rotation. 



tions and forcible, though gradual, expirations, with the result that he 
fully expands portions of the lungs hitherto but imperfectly inflated. 
It is therefore of value in patients with poorly developed chests, in 



604 



REMEDIAL MEASURES OTHER THAN DRUGS 



cases after an attack of pneumonia, when complete resolution is long 
delayed, and in instances of deficient pulmonary expansion because of 





Fig. 100. — Wing standing, knee bending 
or courtseying. 



Fig. 101. — Astride, forward bending 
or hewing. 





Fig. 102.— Half wing, half stretch, 
standing; forward bending or sawing. 



Fig. 103. — Wing standing, leg 
circling. 



adhesions following an attack of pleurisy. In cases of empyema after 
drainage is established it is useful in that it aids drainage, keeps the 
pleural cavity free from pus, and gradually causes the lung to descend 



INHALATIONS 



605 



once more into the lower part of the thorax. This practice is a very 
useful one in children, who may otherwise suffer from deformity due to 
collapse of one side of the chest if the lung is not properly expanded. 
It is not to be practiced immediately after the removal of a pleural 




Fig. 104. — Arrangement of bottles for promoting lung expansion. 

effusion or empyema, because time must be given the lung to expand 
naturally and adjust itself to the relief of pressure. It must be used 
with caution in pulmonary tuberculosis because forcible expiratory 
strain may induce pneumothorax. 




Fig. 105. — Denison's resistance inhaler. When in use the cap at the end of the 
inhaler is removed and air is drawn into the square chamber, which contains a piece 
of folded absorbent paper or cotton wet with some of the volatile oils named in the 
text. The air then passes to the patient by way of the mouth-piece, meeting, how- 
ever a resistance valve on the way designed to produce forced inhalations. On 
expiration the air goes through the mouth-piece as far as the perfoiated elevated 
column, where, by a valve, it escapes. By means of the cap on top of this column the 
resistance offered by the valve to the escape of the air is increased or diminished as 
is desired, so that the patient expires against resistance. 



Another form of apparatus, designed for the same purpose as that 
just named, is "Denison's Resistance Inhaler." (See Fig. 105.) The 
physician having determined that the patient is to inhale air against 
resistance, the valve is fixed to yield to a pressure caused by his forci- 
ble inspiration. On the other hand, when the patient exhales the 
muscles of the chest must use sufficient pressure to force the air 



606 REMEDIAL MEASURES OTHER THAN DRUGS 

past the expiration valve. The result is that every part of the 
lung is expanded, the respiratory muscles are exercised and strength- 
ened, and what might be called slovenly or imperfect breathing is 
corrected. 

We now pass to the consideration of inhalations designed to carry 
medicinal substances into the lungs for their effect on the respiratory 
tract or to influence the general system, not including, however, the 
use of general anesthetics. The air respired may be medicated by 
the following methods : (1) Setting free in the air of the room volatile 
substances derived from chemical or vegetable sources, using materials 
which are naturally volatile or which can be made so by the aid of 
dry or moist heat (2) The use of a mask or inhaler so arranged 
that a part at least of the inspired air must pass through or over a 
sponge or piece of cotton moistened with the medicament. (3) The 
nebulizing of substances which are not volatile, by the use of com- 
pressed air. 




Fig. 106. — Chamber inhaler (Hassall). The shelves are made of cotton cloth, upon 
which is poured the medicine to be employed. 

The use of chloride of ammonium fumes in cases of chronic bron- 
chitis is described in the article on Ammonium Chloride. In cases 
of spasmodic croup a few crystals of menthol placed in an iron spoon 
may be volatilized over a gas jet or lamp chimney, and so diffuse the 
vapor through the air. (See Croup.) 

Creosote is said to produce very good effects in whooping-cough, 
and in bronchitis in its later stages, if cloths wet with it are hung 
about the room. So, too, turpentine, terebene, eucalyptol, and simi- 
lar substances can be used in place of creosote, and in doing so the 
apparatus for diffusing these drugs in the air described by Hassall 
may be employed (Fig. 106). 

In other instances it is better to set free these and other substances 
by the aid of steam, allowing the steam to escape freely into the air of 




Fig. 107. — Croup kettle and inhaler. 




Fig. 108. — Steam vaporizer. 



608 REMEDIAL MEASURES OTHER THAN DRUGS 

the room or to enter a "bronchitis tent." (See article on Bronchitis.) 
5 to 20 minims (0.3-1.3) of any of the substances just named may be 
added to the water when it is boiling. Menthol may also be so used, 
placing 2 to 5 grains (0.12-0.3) in the hot water at a time. The steam 
allays irritation by increasing the moisture in the air of the room, 
checks coughing, and aids the action of the drugs. Steam usually 
does badly, however, if there is an excess of secretion in the lungs. 
The drug to be used may be placed in the water in an ordinary teapot 
heated by a lamp, or gas jet, or the "croup kettle" may be employed 
(Fig. 107), or in its place the appliance shown in the article on 
Bronchitis. In other instances the apparatus shown in Fig. 108 may 
be used. In this arrangement the medicated steam is generated in 
the boiler and then escapes from the upper end of the tube and is 
inhaled by the patient, who brings his face as near to the apparatus as 
the heat will permit. 

The following formula is useful in many cases of pulmonary tuber- 
culosis and bronchitis with a dry cough, if placed in such a steam 
inhaler : 

3— Olei pini sylvestris fSj (30.0) 

Olei eucalypti . f5j (30.0) 

Creosoti f5ss (16.0).— M. 

S. — Place 1 to 3 drams (4.0-12.0) in the water in the boiler and inhale the steam 
three or four times a day. 

If there is excessive cough, \ ounce (15.0) of spirit of chloroform 
may be added to the above prescription with advantage. 

In many cases of acute laryngitis the following formula is of excel- 
lent service if used in this manner: 

I^ — Tinctura? benzoini compositi f 3j (30.0) 

Mentholis gr. x (0.60) 

Spiritus chlorof ormi f3ss (16.0).— M. 

S. — Place 1 to 2 drams (4.0-8.0) in the water in the boiler, inhaling the steam from 
a freshly made watery mixture several times a day. 

After using the steam inhalations the patient must not inhale for 
several hours the outdoor air if it is cold. 

For use with the mask or face inhaler (Fig. 109) or Denison's 
inhaler (Fig. 105) the following formula is valuable in case's of chronic 
bronchitis with excessive cough: 

3— Chloroformi f 5ss (16.0) 

Creosoti f Sss (16.0) 

Mentholis . gr. x (0.6).— M. 

S. — 10 drops on the inhaler every three hours. 

Any one of these ingredients may be used alone. Sometimes where 
it is desired to liquefy tenacious bronchial mucus 10 drops of iodide of 
ethyl may also be placed on the inhaler to act as a stimulant expec- 
torant. The mask or Yeo inhaler must be used almost constantly if 
it is to produce good results. 



INHALATIONS 



609 



Small pocket inhalers containing medicated cotton may be used. 
A small glass tube is partly filled with cotton, and this is kept in place 
by perforated corks fixed in either end. Any of the medicaments 
named may be placed on this cotton, and the air inhaled through the 




Fig. 109. — Yeo's inhaler, made of perforated zinc bound on the edges with chamois 
skin and supplied with elastic loops to go back of the ears or around the head. On 
a sponge placed in the front of the inhaler is dropped the medicine to be inhaled. 

tube. A tube of this sort packed with crystals of menthol, and called 
a "Menthol Inhaler," is largely sold at present. It is of value in 
acute colds. A useful modification of this straight tube is that of 
Evans (Fig. 110). In this apparatusjthe sponge in the bulb is wet 
with the medicament. 




Fig. 110. — Evans's pocket inhaler Half size The finger of the patient may be 
placed over the opening marked 1 when exhaling, and over that marked 2 when 
inhaling. 



There are on the market at the present time a large number of 
so-called vaporizers or nebulizers, which by the aid of compressed air 
force the medicament to be inhaled in a fine spray against the side 
of the glass containing it, in this manner still further comminuting it 
and^causing it to escape from the bottle or bulb as an exceedingly 
" 39 



610 REMEDIAL MEASURES OTHER THAN DRUGS 

fine vapor. The larger ones are supplied, as a rule, with compressed 
air from a force pump or large hand pump. The smaller ones are 
worked by a small hand pump or rubber bulb. The forms employed 
largely by the writer are those of Oliver and the Glaseptic. (See 
Fig. 111.) For a satisfactory use of these nebulizers the medica- 
ment had better be dissolved in an oily fluid. The following formula 




Fig. 111. — Glaseptic nebulizer. 

may be used in such apparatus in coryza or acute inflammation of the 
upper respiratory tract: 

ty— Metholis gr. xx (1.3) 

Camphorse gr. x(0.6) 

Alboleni (liquid) . . f 5j (30.0).— M. 

S. — Place in the nebulizer and inhale the vapor several times a day. 

A somewhat similar formula of even greater value than this con- 
tains, in addition to the above, 2 to 5 grains (0.12-0.3) of chloretone, 
which is useful in that it is anesthetic and sedative to the mucous 
membranes. (See article on Peppermint.) Where the inflammation 
is very severe and acute, it is often well to substitute for the above 
formula the following one: 

1$ — Olei sassafras gr. iij (0.2) 

Oleisantali lUv (0.3) 

Alboleni (liquid) fSj (30.0).— M. 

Sig. — Use in vaporizer. 

In such small amounts sandalwood oil is sedative. If we wish to 
use it as a stimulant expectorant, the quantity may be increased to 30 
minims (2.0). An even more stimulant inhalation in cases of chronic 
bronchitis is as follows: 

I^— Olei eucalypti f"5j (4.0) 

Olei picis liquidse f5ij (8.0) 

Alboleni (liquid) . . . f§j (30.0).— M. 

S. — Use in nebulizer. 

INTRA-ABDOMINAL INJECTION. 

Intra-abdominal injections pf normal saline solution may be 
practised with advantage in cases of great wasting and collapse arising 



INTRAVENOUS INJECTION 611 

from cholera infantum or cholera Asiatica. A fair-sized hollow needle 
is introduced into the peritoneal cavity just below the navel after 
the skin has been thoroughly sterilized. The solution should be at 
about 100° F. as it enters. From 100 to 250 cc may be injected per 
day in the case of an infant. In older children or adults 300 to 500 cc 
or more may be used per day. The fluid should not be used so freely 
as to distend the belly. Absorption is very rapid. This plan can 
be resorted to when hypodermoclysis, or the Murphy drip, are 
impracticable. 

INTRAVENOUS INJECTION. 

Various formulae exist for the preparation of the so-called normal 
saline solution. Some persons are content to employ a solution of 
common salt in the strength of 1J drams (0.7 per cent.) to the quart 
in distilled or sterilized water, but this is a dangerous practice for the 
following reasons: 

Very slight variations in the percentage of normal saline solution 
render it harmful. While the 0.7 to 0.9 may be considered per- 
missible, a solution lower than 0.6 should not be used, because of the 
deleterious effects on the red blood cells and also because it w T ill 
abstract salts from the tissues. If the solution is too strong it will 
cause the cells to part with their fluid. 

It is evident, therefore, that an absolutely correct percentage is 
essential if salt solutions are to be employed. Many years ago Dr. 
Sydney Ringer, in London, found by accident, and proved by careful 
experiment, that a small quantity of calcium was essential to the 
satisfactory use of a sodium chloride solution. Later than this Loeb, 
Howell, Locke, and others have shown, with Ringer, that calcium 
and potassium are both essential, and Howell has concluded that the 
sodium maintains the proper osmotic relations between the cells and 
the fluid, that the calcium is a stimulating agent to the heart muscle, 
and that potassium is essential to its rhythmical contraction and 
relaxation. 

Surgeons and physicians should not be content to employ salt 
solution prepared by haphazard methods. It is vitally important 
that these solutions shall be most accurately prepared, not only 
because they will fail to be of benefit if they are carelessly used, but 
also because the physician may do actual damage and impair his 
patient's chances of recovery if such care is not followed. 

In addition to the effects which may be exercised upon the blood 
and its serum, it is interesting to note that Brown has shown that the 
use of pure sodium chloride solutions is not infrequently followed by 
glycosuria, whereas if calcium is added to the solution such a leakage 
of sugar does not take place. The old rule, therefore, that the normal 
salt solution may be made by adding a teaspoonful of common salt 
to a pint of water ought never to be followed if it can be avoided. 
Mathews also believes, and I heartily agree with him, that when 



612 



REMEDIAL MEASURES OTHER THAN DRUGS 



large quantities of fluid are used in the peritoneal cavity, calcium and 
potassium should be present in addition to sodium chloride in normal 
quantities. 

The best solution, because it at once supplants the blood which has 
been lost or is impure, and because it supports the heart, is: 

Calcium chloride 0.25 

Potassium chloride 0.1 

Sodium chloride 9.0 

Sterilized water 1000.0 cc 




Fig. 112. — The reservoir, tube and needle of this apparatus may be used for intravenous 

injection. 



At the author's suggestion, these sterilized salts are now placed upon 
the market in hermetically sealed glass tubes. The contents of one of 
these vials added to 1 quart (1000 cc) of pure sterile water make a 
normal saline fluid ready for instant use. 

Recent researches have shown that many of the untoward effects 
which follow injection are due, not to the entrance of the fluid, 
but to the fact that the water, even if sterilized by boiling, contains 
the toxic products of bacteria or fungi which are primarily present in 
the water. The water should therefore be distilled as well as boiled 
and used as soon after distillation as possible, and when placed in the 
injection flask should be at 1 10° F., so as to be warm when it enters 
the vein. 



INTRAVENOUS INJECTION 613 

The apparatus and technique used are as follows: 

1. A sterile pitcher, in which is placed the hot salt solution with a 
sterile thermometer immersed in it so that temperature of 110° F. 
may be shown to be present. 

2. A flask such as is used for giving arsphenamine. (See Fig. 112.) 

3. Rubber tubing, at the distal end of which is a nozzle to fit in 
the needle used to enter the vein. In this rubber tube a segment of 
glass tubing or an infusion thermometer should be inserted in order 
that air globules may be discovered and the temperature of the flowing 
fluid watched. The tubing should, of course, be sterile and long 
enough to permit it to be coiled in (4) a basin of hot water so that the 
salt solution as it passes slowly through the tubing to the vein does 
not become chilled. 

5. The skin over the vein, usually one of the arm, is sterilized by 
iodine tincture and washed off by alcohol. 

6. The reservoir is now held so that the tube hangs perpendicularly 
and fluid is poured from the pitcher to displace air from the tube. 
When air-free a clip is placed on the distal end of the tube near the 
nozzle to hold the fluid in and keep the air out if the distal end of 
the tube is lifted. 

7. The needle is now inserted in the vein and as soon as this is 
done the clip is released and, as the solution escapes, the nozzle is 
inserted in the shank of the needle. 

8. The reservoir is held about 1 foot above the arm and at least 
thirty minutes should be used in injecting as much as 1 quart. 

9. If the arm is fat, or the vein collapsed, it may be necessary to 
incise the skin and expose the vessel. 

10. In infants saline solution, or dextrose in 5 per cent, solution (3 
grains to each pound of patient), may be injected into the longitudinal 
sinus through the posterior portion of the fontanelle in the middle 
line. Four to eight ounces (120.0-240.0) is usually enough. (See 
Transfusion and Intra-abdominal Injection.) 

An efficient home-made apparatus can be gotten together by taking 
a bottle of any considerable size, using a cork with two holes. 
Through one of them is placed a glass tube long enough to reach the 
bottom of the bottle and through the other hole is inserted a short tube 
reaching into the neck of the bottle. To the short piece is attached 
a piece of rubber tubing (see above), to the distal end of which is 
attached a hollow needle. By means of adhesive strips running 
from the end to the bottom of the bottle a sling is made, so that when 
the bottle is inverted for infusion it can be hung above the patient. 
When the bottle is inverted the air enters by the long tube and the 
solution escapes by the short one. 

As the injection is given the pulse begins to improve, the respira- 
tions are deeper and less hurried, and if fever is present the tempera- 
ture usually falls. The patient is evidently better, but may enter a 
critical stage, particularly if the water has not been properly pre- 



614 



REMEDIAL MEASURES OTHER THAN DRUGS 



pared, which may come on in from two to thirty minutes. There are 
sometimes a violent chill, a strong, rapid pulse, and in the course of 
three-quarters of an hour a flushing of the skin, followed by profuse 
sweat. The respiration may be labored. The urinary flow is also 
increased, and sometimes water escapes from the bowel. These 
symptoms rarely occur if freshly distilled water is used. Several 
hours later the real benefit appears in convalescence or in marked 
improvement. 

It is important to bear in mind that a very low content of hemo- 
globin is compatible with life if only the bulk of the blood is restored. 





Chart I 








Chart I] 






HOURS 2 3 4 5 6 


2 3 4 5 6 7 


<s> 

UJ 

cc 

0_ 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 

40 


- 














































I 






















h 
































/ 






















/ 






















/ 










| 


































/ 














V 


y\ 




/ 












J 








\ 


7 












I 










1 


































No. 


EFFECT OEftNORMAL 
SALINE. 


No. 2 EFFECT 09 ACACIA) 
NORMAL SALINE, 



Fig. 113. — I, temporary rise of blood-pressure from normal saline; II, maintained rise 

from acacia solution. 



Saline injections may be given to compensate for acute hemor- 
rhage, to diminish toxemia (see Diabetes), and to give the body 
fluid when it has been deprived of it by profuse vomiting and purging. 
(See Cholera.) Unless the conditions are urgent hypodermoclysis 
or proctoclysis may be sufficient in such cases. (See Hypodermoc- 
lysis and article on Peritonitis.) The amount of saline given 
intravenously usually varies from a pint to a quart. 

When diabetic coma (see Diabetes) exists the benefit is often only 
temporary. 

In uremia and in puerperal convulsions the patient should be bled 
before, or simultaneously with, the injection, if the veins are turgid. 

In the treatment of Asiatic cholera it has been found advanta- 
geous to use a salt solution of 1.0 per cent. (See Cholera, Part IV.) 



INTRAVENOUS INJECTION 615 

If there is a tendency to pulmonary edema or general anasarca 
injections are contraindicated. 

A saline solution is used intravenously by some persons to com- 
bat shock. Experience has shown that it is useless for this purpose 
because the dilated vascular system is not constricted by its use 
and a pint or quart of fluid does not increase the bulk of blood where 
it is needed, if at all, because the vessels relax still more and the fluid 
transudes into the tissues. (See Shock, Part IV.) Any temporary 
gain is due to the heat in the solution. This temporary effect on 
blood-pressure is shown in Chart I, Fig. 113. Only whole blood 
from a proper donor does good (see Transfusion), or a saline solution 
of such hypertonicity that it takes fluid from the tissues, instead of 
pouring it out into them, is of any value. (See below and article 
on Cholera for Hypertonic solutions.) 

Bayliss and others have advised the employment of gum acacia 
in the strength of 60 grams to each 1000 cc of normal saline, or 
in a hypertonic solution made by doubling the amount of sodium 
chloride and of the calcium chloride, but not the potassium. They 
believe that the viscosity of this fluid renders it capable of main- 
taining blood-pressure better than normal saline because it does 
not transude and also because it is not so quickly lost through the 
kidneys. Acacia has the advantage over gelatin of being easily 
sterilized and, as it contains no protein, there is no danger of ana- 
phylaxis. The effect of such a fluid on blood-pressure is diagram- 
matically shown in Chart II, Fig. 113. 

As gum acacia in normal salt solution has an acid reaction, it 
should be neutralized before using. On the other hand, the solu- 
tion should not be alkaline. Take 10 cc of the solution, dilute to 
25 cc with distilled water and titrate with yo normal sodium hydrox- 
ide (NaOH), using phenolphthalein as an indicator. Neutralize the 
whole solution by the calculated amount of NaOH. The quantity 
of gum saline solution used is usually about 500 cc and twenty 
minutes is taken in the injection. As gum acacia is not sterile the 
solution should be sterilized by placing the bottle holding it, after 
it is wrapped in gauze, in an autoclave at 120° C. for half an hour. 
If no autoclave is at hand the solution should be boiled for five 
minutes and allowed to stand for a day to see if a sediment forms, 
which should be gotten rid of by siphoning off the supernatant 
liquid. Before the solution is used it should be filtered through 
sterile absorbent cotton resting in a layer of sterile gauze in a funnel 
placed in a sterile bottle and then filtered again through coarse filter 
paper, so that the fluid is perfectly clear. 

The intravenous injection of medicines is a method which is to 
be employed only under extraordinary circumstances and with only 
a few drugs, as, for example, arsphenamine in syphilis and quinine 
in severe malarial infection. (See Arsphenamine and Cinchona.) 
The injection should be made very slowly, and the drug should be, 



616 REMEDIAL MEASURES OTHER THAN DRUGS 

as a rule, well diluted so that it will not reach the heart in a con- 
centrated form, temporary cardiac depression being thereby avoided. 

The objections to intravenous injections are several. In the first 
place, the veins are apt to be collapsed and hard to find, and it is 
difficult to puncture one without wounding the opposite wall of the 
vessel. Again, phlebitis is a possible sequel, and thrombosis and 
embolism are by no means impossible. 

It is needless to say that the solution of the drug which is injected 
into a vein should always be nearly neutral or alkaline in reaction in 
order to avoid coagulation of the blood. 

LAVAGE. 

This is a term applied to washing out of the stomach in cases of 
gastric dilatation, chronic gastritis, in obstinate vomiting, and more 
rarely in cases of gastric carcinoma. It is particularly valuable in the 
two first-named conditions not merely for its curative power, but also 
to rid the stomach of mucus and render it clean before fresh food is 
ingested. 

The liquid employed should always be warmed. For an adult 
a tube should be used of at least four and a half to five feet in length, 
of which eighteen inches pass into the mouth, the remaining portion 
reaching to the basin when lowered to allow siphon age. The ques- 
tion as to the variety of tube to be employed is a vital one, since 
a poorly devised apparatus not only gives no relief, but disgusts 
both the patient and the physician with the technic of the method. 
The tube should be more like a hollow bougie than a catheter, in 
order that its caliber may be great enough to carry off some of the 
semisolid materials present. If this rule is not followed, two evil 
results follow: In the first place, the tube and its apertures rapidly, 
or even at once, become clogged; secondly, the liquid is drained 
away leaving behind a mass which is semisolid, to be sure, and less 
bulky, but which is nevertheless the quintessence of the nastiness 
of fermentation, and quite as qualified to contaminate any fresh 
food on its entrance as the liquid would be. 

The holes in the gastric end of the tube should therefore be of 
sufficient size to take in fairly large masses. In most cases the 
ordinary siphon may be used, but where there is any solid food or 
resistance suction by means of a stomach-pump is necessary. 

The best tube for adults in No. 20, made of red Para rubber with 
lateral holes. 

The methods by which lavage is employed, in addition to those 
which have been named, are as follows : The tube should be passed 
backward against the roof of the mouth, so that by following the 
curve of the hard and soft palates it is directed into the pharynx 
and esophagus, and then by gentle pressure forced into the stomach. 
At the same time the patient should be directed to swallow. The 



LAVAGE 



617 



mucus in the throat sufficiently lubricates the tube, and oil is not to 
be used. If gagging is excessive, the pharynx may be first painted 
with cocaine. The irritability of the pharynx usually rapidly dis- 
appears, and it is surprising how quickly the patient becomes accus- 
tomed to the operation, and submits to it without any feeling of 
discomfort. After the tube has reached the stomach a small funnel 




Fig. 114. 



-The stomach-tube having been passed, the funnel is filled from a pitcher 
and elevated to urge the water into the viscus. 



is to be fitted in its external end, which is then held above the head 
of the patient while water prepared in the way already mentioned 
is poured into it until the stomach is filled, when the funnel end is 
lowered and the stomach is emptied by siphonage. 

The stomach-pump has one very serious disadvantage, which is 
present with even more force in the case of a child than in an adult 
—namely, the danger of injury to the coats of the organ. This 



618 



REMEDIAL MEASURES OTHER THAN DRUGS 



apparatus is also more costly and cumbersome, and for children 
the siphon is powerful enough in its action to take away all excuse 
for the use of the more complicated apparatus unless the contents 
of the stomach are in bulk. 

It is particularly necessary in children, if a catheter is used and 
on account of the lack of intelligent aid and their liability to gulp, 
that every care should be taken that the tube does not slip entirely 
out of reach into the stomach; and for the prevention of this danger 




Fig. 115.— Just as the last portion of the water is about to disappear down the tube 
the funnel end is lowered and the contents of the stomach are siphoned out. 

a string should be attached to the eternal end of the catheter before 
it is introduced, and the tube should always be at least thirty inches 
in length. 

LEECHING. 

Leeching is a method of abstracting blood for the purpose of 
relieving local inflammations or acute congestions. There are two 
forms of leech commonly employed in medicine, both of which are 
imported. A small leech is found in many streams in the United 
States. Leeches, after attaching themselves to the skin by means 



LEECHING 



619 



of their sucking apparatus and teeth, secrete a liquid which prevents 
coagulation of blood, and this accounts for the persistent hemorrhage 
sometimes seen after a leech-bite. 




Fig. 116. — Showing the application of leeches in front of and behind the ear, for 
the relief of the early stages of acute otitis. The auditory meatus is plugged with 
cotton to prevent the leech from entering the canal by accident. 

Therapeutics.— The reasons for using venesection or depletion are 
considered farther on, and we can therefore pass directly to the 
uses to which leeches are put. In cases of meningitis they may be 
applied to the temples or to the nape of the neck, and they are useful 
in the treatment of swollen joints, such as occur after sprains. In 
orchitis they should not be placed upon the scrotum, but on the 
groin. In conjunctivitis or inflammation of the eye they should be 
applied upon the temple or back of the ears, not upon the lid itself. 
The effect of leeching is not only that of depletion, but also one of 
counterirritation. 



Richaud's table indicating the areas of the skin to which leeches or cups are to be 
applied to directly affect the viscera by abstraction of blood. 



Areas to be Depleted. 



Appendix. 



Liver, 



Uterus. 



Testicle. 

Pericardium. 

Lung. 



Eye. 



Areas to which Depletion is 
to be Applied. 

Groin. 



Anus. 



Anus. 



Bladder and prostate. Anus. 



Tonsil. 



Groin. 

Third, fourth, and fifth left 
intercostal spaces. 

Third right intercostal 
space between the verte- 
bral column and shoulder- 
blade. 

Mastoid apophysis. 



Angle of the jaw. 



Paths of Communication 
through which depletion 
Takes Place. 

Spermatic veins, circum- 
flex, iliac, and ileolum- 
bar veins. 

Portal vein, anal and peri- 
neal vessels, hemorrhoid- 
al veins. 

Uterine and hemorrhoidal 
veins. 

Prostatic and hemorrhoidal 
veins. 

Spermatic and inguinal 
veins. 

Pericardial and internal 
mammary veins. 

Bronchial and azygos veins 
and superior intercostal 
veins. 

Ophthalmic vein, cavern- 
ous sinus, petrous and 
lateral sinus. 



620 REMEDIAL MEASURES OTHER THAN DRUGS 

Application.— Leeches if singly applied may be placed on the skin 
under an inverted wineglass or under a large pill-box to prevent them 
from migrating before they take hold. If they will not take hold, a 
little sweetened milk may be placed on the skin or a drop of blood 
extracted from the finger may be placed there. In all cases the 
skin should be carefully washed before the leech is used. When 
the leech has taken enough blood, it can be made to let go its hold 
by sprinkling it with salt. Each leech will take about 1 dram of 
blood. Leech-bites should be watched lest prolonged consecutive 
bleeding exhaust the patient. In case of such an accident, a com- 
press and styptics are to be employed. As leech-bites make small 
permanent scars, the leech should not be applied on the face or 
other exposed surface of the skin. 

LUMBAR PUNCTURE. 

Lumbar puncture consists in the introduction of a strong hollow 
needle of large caliber, or better, a fine bevelled cannula with a trocar 
between the third and fourth or fourth and fifth lumbar vertebrae. 
The operation can be performed when the patient is sitting up, 
with the spine bent by bending forward (see Procaine), but is best 
done, particularly in children, with the patient lying on the side 
with the neck, knees and hips sharply flexed so as to separate the 
vertebrae. This sharp flexion is essential particularly for a novice. 
The easiest way to find the level at which the puncture is to be 
made is to draw a line across from the crest of one ilium to the crest 
of the other, which line runs between the third and fourth lumbar 
vertebrae. In children in whom the vertebral spines are not well 
developed the best point for inserting the needle is the middle line, 
but in adults in whom these spines are developed and whose vertebral 
bodies are better separated a point about one-eighth to one-quarter 
inch below the middle line, the patient being on his side, is the place 
of election. The direction of the needle should be slightly upward 
and forward to a distance of about 2 centimeters (f inch) in children 
and 4 to 6 (1J to 2 inches) in adults. As soon as the subarachnoid 
space is reached the cerebrospinal fluid will flow freely or even spurt 
out if the intraspinal pressure is abnormally high. A dry tap may 
be due to (a) failure to enter the subarachnoid space, (6) to going 
too far and fetching up on the bone on the far side, (c) to minute 
piece of bone, cartilage or other tissue, plugging the end of the 
cannula as the trocar is introduced. It may rarely occur from a 
fragment of lymph when the fluid is purulent or to adhesions as the 
result of an acute inflammation. The first cause of failure is to be 
relieved by pushing the cannula further in. The second by with- 
drawing slightly. The third by rotating the trocar in the cannula 
or rotating the cannula. If these measures fail make another 
puncture between the second and third lumbar vertebrae. If the 



LUMBAR PUNCTURE 



621 



pulse becomes rapid and the blood-pressure falls as the fluid is 
withdrawn the tapping must cease at once. If a young child is 
tapped a bulging fontanelle becomes flattened. As soon as a tend- 
ency to concavity of the fontanelle is produced the operation must 
cease. After a spinal puncture the patient may have severe head- 
ache. This can sometimes be avoided by having the patient stay 
in bed for twelve to twenty-four hours. Absolute surgical asepsis is, 
of course, essential. 

Therapeutics.— Spinal puncture is resorted to for three purposes— 
namely, treatment, diagnosis, and spinal anesthesia. (See Pro- 
caine.) For treatment it is indicated chiefly in the convulsive 
seizures of children and in adults with uremia. If convulsive seizures 
are recurrent, spinal puncture by giving relief to cerebrospinal 
pressure will arrest these in a fair proportion of cases. Usually 
about 15 to 20 cc are withdrawn in adults, but as as much as 40 cc 




Fig. 117.— A, space between the third and fourth lumbar vertebrae for subarachnoidean 
injection (Quincke's area) ; B, area of puncture suggested by Turner. 

or even 60 cc may be taken away. If the fluid is turbid it is a sign 
of infection of the meninges, most commonly by the meningococcus 
or by the pneumococcus, and if the infection is severe it may be not 
only turbid but yellowish or greenish. The sugar normally found 
present by the copper test is absent and a large number of poly- 
morphonuclear cells are seen under the microscope. So, too, there 
will be found a marked increase in globulin. The diagnosis is con- 
firmed by finding a specific organism. When the tubercle bacillus 
is the cause of meningitis the fluid is clear, there is an excess of small 
mononuclear lymphocytes, and there is not a loss of sugar to so great 
a degree or an increase in globulin. When the diplococcus of Weich- 
selbaum is found, 30 cc of the cerebrospinal fluid is drawn off and 
substituted by the same amount of antimeningitis serum (see Anti- 
meningitis Serum) daily until the fluid is clear and the patient 
convalescent. 



622 REMEDIAL MEASURES OTHER THAN DRUGS 



MINERAL SPRINGS AND CLIMATE. 

This article is intended to give the practitioner and student a 
general idea of where to send patients who can afford to resort to 
treatment depending upon watering-places and climates. It is 
manifestly impossible to include the names of all the health resorts, 
and the object is to indicate the diseases which are benefited by 
these treatments, taking certain well-known resorts as types of each 
class. 

Springs. 

Medicinal springs are usually resorted to for the double purpose 
of drinking and bathing in the waters, although in many instances 
one of these methods so far exceeds the other in popularity that it 
alone is employed. 

For general purposes we may divide these medicinal or beneficial 
waters into four classes— namely, those which act, first, by their 
purity, chiefly; second, by the presence of more or less active alkaline 
ingredients; third, by the heat which the waters contain as they 
leave the earth; and fourth, by the sulphur or radio-active sub- 
stances which they contain. The first class— namely, those which 
act by reason of their purity— are indicated chiefly in cases where 
through high living or other cause the system becomes laden with 
impurities through imperfect elimination of tissue-waste. Most of 
the popular lithia waters depend chiefly upon this ability to dissolve 
effete materials, and very little upon the lithia, which is often present 
in very small amount. (See Lithium.) Aside from their purity, 
they also act by reason of the salts of sodium and calcium which 
they contain. Good results follow their use in the so-called uric- 
acid diathesis where the urine is scanty, high-colored and acid. 
They do good in cases of irritable bladder by washing out this viscus 
with mild urine in large quantities, and because of this influence 
are credited with wonderful cures of vesical calculus. When vesical 
calculi have broken down while these waters were being taken, the 
fortunate result has been coincidence rather than due to medicinal 
interference. It is impossible for them to dissolve stones, but their 
constant use may prevent the formation of new ones. Perhaps the 
best representative of pure natural waters is Poland water, from 
Poland, Maine. 

A subdivision of this class consists of those waters which contain 
somewhat larger amounts of mineral substances, chiefly potassium, 
sodium, and calcium salts. Because of the power possessed by alka- 
line salts in aiding in oxidation, these waters are used in cases where 
the effete matters of the body seem to escape only partly oxidized, 
and where the kidneys, and perhaps the liver, seem torpid. Such 
springs are the Kissingen and Vichy at Saratoga. If very mild 



MINERAL SPRINGS AND CLIMATE 623 

purgative properties are also desired, the Geyser Spring at Saratoga 
may be used. In Europe the most famous springs of this class are 
at Vichy (Grande Grille), Vals, and Contrexeville in France, and 
Kissingen in Bavaria. 

The second class of springs are those which contain salts of sodium, 
calcium, potassium, and magnesium in sufficient amount to possess 
very active diuretic and purgative properties. They find their 
therapeutic application in cases of hepatic torpor or congestion 
associated with gouty or rheumatic tendencies, particularly in those 
individuals who have been high-livers, who lay on too much fat, so 
clogging their organs, and, finally, in those who through illness or 
exposure to hot climates have subacute or chronic atony of the 
liver, of the organs of digestion, and of the lymphatics. Nearly 
always these patients also suffer from more or less constipation and 
gastro-intestinal catarrh, and are often obese. The sulphate of 
sodium is an ingredient of many purgative mineral waters, and the 
activity of a water depends very often on the percentage of this 
salt which is present. The purgative action of a water also depends 
upon the time at which it is taken. When taken on an empty 
stomach it is of course more active. When taken early in the morn- 
ing before eating and at the natural temperature, such a water 
produces a loose watery movement, not only unloading the bowel 
of fecal matter, but by its alkalinity loosening catarrhal secretions 
and unloading the liver of congestion. The quantity to be taken 
in twenty-four hours varies from 1 to 4 pints, but this question can 
only be decided by the local physician, who studies the effect of the 
water on the patient. The best-known waters of this class are the 
Champion, Congress, Hathorn, and Carlsbad Springs at Saratoga, 
New York, the Crab Orchard in Kentucky, and the springs of Carls- 
bad and Marienbad in Bohemia, and Friederichshall in Germany. 
These waters are chiefly used at the site of the springs, except 
Hathorn and Friederichshall which are bottled and used in this 
country. Of the sulphate purgative waters the best known are 
Hunyadi and Apenta from Hungary, and Pluto of Indiana. These 
are bottled for transportation and widely used. 

The hot springs depend chiefly on their heat, as already stated, 
and differ in chemical composition. They find their value in the 
treatment of chronic skin diseases, specific or otherwise, and also 
are useful in aiding in the treatment of rheumatism, gout, and syphilis. 
Their good results are produced by their heat, which varies from 
93° to 150° F., and the advantages always derived from properly 
employed hydro therapeutic measures. It is in chronic or subacute 
cases that they do the most good. Hot baths are also of great value 
in the treatment of chancroid and malignant syphilis. The results 
achieved depend upon the increased activity of the skin, the improve- 
ment of the peripheral circulation, and the increased powers of 
absorption of mercury produced through increased cellular activity. 



624 REMEDIAL MEASURES OTHER THAN DRUGS 

Patients should always select a competent local physician at such 
resorts. 

In cases of syphilis the methods of treatment to be followed are 
as follows: The patient should take the bath at a temperature of 
90° F., and remain in it for about twenty minutes. After this he is 
rapidly but thoroughly dried by an attendant, who at once proceeds 
to rub into the skin of one thigh an amount of mercurial ointment 
varying from a few grains to a dram. This is well rubbed into, 
not smeared over, the skin of a different limb after each bath. The 
number of baths and inunctions depends upon the condition and 
necessities of the case, care being exercised not to push the mercury 
too freely in those who are very susceptible to its effect. These 
baths also aid in the absorption of mercury when it is administered 
by fumigation. The most celebrated of these springs are the Hot 
Springs of Arkansas and those found at Aix-la-Chapelle (Aachen) 
in Germany. 

As types of the fourth class of springs we have the White Sulphur 
Springs in West Virginia and the Richfield Springs in New York, 
which are used for the relief of catarrhal inflammations of the mucous 
membranes of the alimentary canal and respiratory passages, and 
more rarely for catarrhal states of the geni to-urinary tract. Not 
only do they exert the peculiar remedial powers long known to 
belong to sulphur and its compounds by. reason of the sulphuretted 
hydrogen gas contained in them, but they also possess distinct 
purgative effects. Their chief mineral constituents consist of sul- 
phate of sodium and magnesium, which unload the bowels and 
portal system in the same manner as do the Champion, Congress, 
Hathorn, and Carlsbad Springs at Saratoga and those at Crab 
Orchard. Taking the White Sulphur as a type of its class, it is 
better than the Saratoga springs in catarrhal states for the reason 
given. 

Climates. 

The practitioner is most frequently consulted as to the possible 
benefit of climatic changes by persons suffering from pulmonary 
disease, such as tuberculosis of the lungs, asthma, chronic bronchitis, 
and emphysema— more rarely by those convalescing from pneumonia 
or other severe acute illness. 

The general rules to be followed in all cases are— first, choose 
a climate having as large a number of clear days as possible, in order 
that an out-of-door life in the sunshine may be had constantly; 
secondly, the nearest place to the home which is available in order 
to avoid fatigue, expense, and homesickness; and thirdly, see that 
the resort chosen has comfortable accommodations, good food, good 
drug-supplies, and a capable physician at hand in case of need. 

In a case of tuberculosis and in all patients suffering from the 
pulmonary complaints named above the following rules may be 



MINERAL SPRINGS AND CLIMATES 



625 



adhered to, except in persons suffering from attacks of acute bron- 
chitis, who always need a climate providing moisture and warmth. 
Some tubercular patients do best in a high, dry air, and others in 
a lower and more moist temperature— the first being represented 
by that of Colorado Springs (6000 feet) or Silver City in America 
and by San Moritz (6000 feet) and Davos Platz (5000 feet) in Switzer- 
land, where the altitude is not only very great, but the air very cold 
in winter. The days in these places are many of them clear, but 
in Colorado they are apt to be windy. Feeble persons cannot stand 
high winds, as a rule. The second climate is represented by that 
of Florida and Southern California. 




Fig, 118. 



-Ghest outline before residence at Davos — solid, 
(William's diagram.) 



After residence at Davos 



In those cases in which a mild climate is useful, this can be obtained 
at San Diego, a place where there is virtually perpetual summer. At 
Asheville, N. C. (2200 feet), or Thomasville, Georgia (330 feet), 
the air is moderately dry. A spot is desirable where a patient can 
remain the year round, and, if well enough, engage in business, 
avoiding cold, sharp March winds of the Middle, Eastern, or North- 
western States, and the necessity of leaving Florida on the advent of 
summer. 

Physicians have attempted for years to formulate rules for phthis- 
ical patients as to the climate to be sought. In very many cases the 
various health resorts have to be chosen by experiment, not by 
judgment beforehand. In cases of phthisis with profuse bronchial 
secretion, a high, dry climate is generally the better unless the heart 
is feeble, but in cases which suffer from dryness of the air-passages 
a sea- voyage or a warm, moist climate is better, on general principles. 
It is probably true, however, that high altitudes and rarefied air are 
not to be sought where a distinct tendency to hemorrhage is present, 
40 



4 

626 REMEDIAL MEASURES OTHER THAN DRUGS 

unless the ascent or removal to the rarefied air is very gradual, 
several weeks being passed before the lung is exposed to the low 
pressure of great heights. The cases in which high altitudes do 
good are those which naturally have poor thoracic development or 
suffer from chronic pleurisy with deficient expansion of the lung 
after tapping. A high altitude not only improves respiratory capac- 
ity and develops the chest, but also increases the richness of the 
blood in its red cells as to number and as to their content of hemo- 
globin. The following excellent advice given by White in his General 
Therapeutics is worthy of repetition: 

"It is of such importance that only suitable cases should be sent 
to high altitudes that we must point out those that are unsuitable: 

" 1. Those in whom there is considerable affection of the bronchial 
tubes, for the dryness of the climate increases the kind of bronchitis 
which commonly accompanies phthisis. 

"2. Patients with much emphysema or bronchiectasis, because of 
the probably diminished absorption of oxygen and the difficulty of 
respiration experienced on first arriving. 

"3. Patients with disease of the heart must not go to a high alti- 
tude, because of its effect upon the pulse and upon respiration. 

"4. Cases liable to acute febrile attacks, whether or not these 
indicate an occasional increase of mischief in the lungs, should 
remain on a low level. 

"5. Patients who are very excitable or suffer from insomnia should 
not go, for a visit to a place at a great elevation promotes these 
symptoms. Women do not acclimatize so well as men. 

"6. Cases in which there are very extensive lesions, or which are 
very advanced, are unsuitable. 

"7. Pneumonic phthisis, if at all acute, is made worse by a high 
altitude. 

"8. Patients who cannot take exercise should not go. 

"9. The very old and the very young had better be treated at 
home. 

" 10. Sir Andrew Clark states that patients who go to Alpine health 
resorts suffering from albuminuria, or those who develop it whilst 
there, seldom derive any good from their change. 

"There are many conditions which have been thought to contra- 
indicate this treatment, but which do not, and they had therefore 
better be mentioned. They are: 

"Pulmonary Hemorrhage.— It is now known that this, so far 
from being a contraindication to treatment by high altitudes, is 
actually relieved by it. The exact explanation cannot be given." 

With this the author of this work cannot agree. 

"Fever.— If this is not excessive, and if it does not indicate 
any active changes in the lungs, it is often improved. 

"Simple Diarrhea and Simple Dyspepsia. — These are both 
benefited. 



MINERAL SPRINGS AND CLIMATES 627 

"Night-sweats.— There is a common belief that these forbid 
this treatment; on the contrary, they often disappear on removal 
to a high altitude. 

"The Presence of Cavities.— This is not a contraindication 
unless a very large area of lung is destroyed." 

There is no need, after these two lists, to say what cases are suit- 
able for this climatic treatment: it may, however, be observed that 
those in whom there is threatened phthisis, with a strong hereditary 
predisposition, and those of imperfect thoracic development, are 
much benefited. 

To these rules the author would add the following invariable 
rule: viz., Do not send a case away to die. If the disease is so far 
advanced that no good can be derived from a trip abroad, it is 
cruel to make a wretched patient exhaust his strength, his money, 
and his happiness by seeking health which it is impossible for him 
to obtain. A patient of the writer's returned on one occasion from 
a stay of a few days at a noted Southern resort for consumptives, 
and, when reprimanded for his imprudence, replied: "I would 
rather be at home, and die at once, than drag out a few more years 
surrounded by a crowd of coughing, hawking, and wasting con- 
sumptives." The reply evidences clearly the necessity of avoiding 
"consumptive hotels" as much as possible in these cases, and in 
directing the mind of the patient from depressing thoughts and his 
own ailment, and that he may avoid secondary infection from other 
sufferers. 

In the treatment of renal and cardiac disease high altitudes are 
contraindicated, as a rule. The chief desideratum is out-of-door life 
with avoidance of chilling of the skin by sudden changes in tempera- 
ture or strong winds. San Diego and many other places in Southern 
California represent the necessary climate in such cases. 

There is a class of persons who often have no actual disease of a 
chronic type, who nevertheless pass healthier lives if away from rig- 
orous climates for at least part of the year. Without having acquired 
tuberculosis, their lungs are delicate naturally or because of attacks 
of disease, or, again, they become asthmatic or rheumatic in cold 
weather. In this country, Pinehurst and Thomasville, Ga., or San 
Diego or Santa Barbara, California, afford the climate desired, while 
in Europe patients are sent to what is known as the "Riviera," 
which is the district bordering on the Mediterranean Sea from Genoa 
to Nice and which is dotted with climatic resorts. This district has 
often as many as two hundred clear days between October 1st and 
May 1st. In the French Riviera the resorts are Cannes, Nice, 
Monaco, Monte Carlo, and Mentone; in the Italian Riviera, Bordig- 
hera and San Remo. In Naples and Spezzia the climate is more 
damp and colder, but nevertheless quite sunny. So much depends 
upon the location of the hotels in these places, as far as their salubrity 



628 REMEDIAL MEASURES OTHER THAN DRUGS 

in relation to air and dampness is concerned, that the patient should 
always consult a local physician before settling down permanently 
at any of these resorts. 

PHYLACOGENS. 

This term "phylacogen" is applied to sterile aqueous solutions 
of derivatives of bacteria which have been grown on artificial media. 
No bacteria are present, because they are first killed and then removed 
by filtration through porcelain. The solution is also tested after 
this to be sure it is sterile. While, therefore, phylacogens differ 
materially from the so-called bacterins or vaccines in themselves 
(see Vaccine Therapy), the principal of their employment is practi- 
cally identical in the sense that they are designed to stimulate the 
protective processes of the body to greater effort. They are closely 
allied to the so-called polyvalent vaccines because each individual 
preparation of phylacogen is composed of the products of a number 
of pathogenic germs, with an excess of one particular germ which 
is known to be the chief cause of the disease from which the patient 
is suffering. The organisms used are the Streptococcus pyogenes, 
Bacillus pyocyaneus, Diplococcus pneumonise, Bacillus typhosus, 
Bacillus coli communis, Streptococcus rheumaticus, and the Strepto- 
coccus erysipelatus. The product from a culture of these germs is 
called polyvalent or Mixed Phylacogen. The fundamental idea of 
this method is that in all acute infections, although one germ may 
be dominant, it has associated with it a host of others in smaller 
number which are aiding it in overcoming the patient. 

When it is desired to treat a specific illness, as, for example, acute 
articular rheumatism, a special culture of the specific germ is pre- 
pared and its filtrate is added in equal amount to the ordinary 
mixed phylacogen just described. The same process is followed 
when typhoid, erysipelas, croupous pneumonia, and other infectious 
diseases are to be treated. 

The product, however, is so dilute as not be severely toxic, it 
being estimated that the lethal dose would be about eighty times the 
maximum ever given to a patient. 

These products give fully as good results as vaccine therapy, and 
seem to be peculiarly efficacious in acute and chronic rheumatism of 
the joints, gonorrheal rheumatism, and in erysipelas and in pneu- 
monia. Too often they are employed when the patient is so nearly 
dead that the case is hopeless. Manifestly two factors are needful 
in their use— namely, a correct diagnosis and enough vitality in 
the patient's tissues to enable him to react. 

Administration.— The phylacogens are given hypodermically and 
intravenously. The syringe is filled from a hermetically sealed glass 
ampoule. The skin where the injection is to be given should be 
carefully sterilized, and as the injection is bulky the abdominal wall, 



PHYLACOGENS 629 

the back, or the outside of the thighs should be the part chosen for 
injection. The injection should be made hypodermically and not 
into the superficial fascia or into a muscle, and subsequent injections 
should be given in other portions of the body than the area of the 
first injection. The author usually begins with a 1 cc dose and 
increases it by 1 or 2 cc each day or every other day. In urgent 
cases the injection may be given intravenously. This also holds true 
of cases which resist subcutaneous doses in the sense that no better- 
ment follows their use. In a period, varying from one to four hours, 
after the injection subcutaneously there is a distinct constitutional 
reaction, the rise of temperature varying from 1 to 4 or even 5 
degrees, often preceded or accompanied by a chill and a sense of 
numbness. While these symptoms are alarming, they are fleeting 
and not followed by bad results. Simultaneously with the consti- 
tutional symptoms described the pulse may increase in speed 10 to 
50 beats above the normal, and occasionally there may be some 
nausea and moderate diarrhea. Occasionally, stomatitis or herpes 
has been observed. 

Locally, the injection results at the end of from six to twenty- 
four hours in redness and the part may be painful and tender. The 
first dose for hypodermic use is 2 cc increased daily to 10 cc accord- 
ing to the severity of the infection and the ability of the patient to 
stand a reaction. 

When given intravenously a sharp needle is attached to the syringe 
and, after the skin is sterilized, it is plunged into a vein, usually 
the median cephalic. The reaction following a full intravenous 
dose is usually quite severe, the face may be pinched, the lips blue, 
the pulse may be feeble and at times intermittent, and the respira- 
tions may be shallow and rapid. The reaction from an intravenous 
dose usually comes on within thirty minutes and is characterized 
by a severe chill, such as is seen in very severe cases of malarial fever. 
Because of the severe reaction when used intravenously, the first 
dose should always be given by the subcutaneous method to determine 
the ability of the patient to gain benefit from the effects of the 
remedy. 

When used intravenously the initial dose should be \ to J cc. 
The second dose 1 cc increasing 1 cc for each subsequent dose, but 
not exceeding 5 cc. The interval between doses is usually twenty- 
four hours. Very young or very aged patients should receive J to 
J the dose for adults. 

Contraindications.— Where the patient is moribund or in a hopeless 
condition, or a sufferer from severe and dangerous cardiac disease or 
advanced arterial and renal disease, phylacogen should be used with 
caution, if at all, and never given intravenously. Nephritis is also 
a contraindication. If cyanosis is great after the first injection, the 
subsequent ones should be smaller. 



630 REMEDIAL MEASURES OTHER THAN DRUGS 

POLLEN PROTEINS. 

It seems to be pretty well determined that the multiple symptoms 
covered by the general term "hay fever" are due to the entrance 
into the respiratory tract of protein substances which are derived 
from the pollens of the flowers and various grasses, shrubs and trees. 
In other words, such patients are sensitized to these protein sub- 
stances and react to them as does a patient who has been sensitized 
by the injection of protein substances derived from blood serum. 

Acting upon these basic facts the attempt has been made to 
protect so-called hay-fever patients by prophylactic injections of, 
and to treat the disease when already in existence by, derivatives of 
various forms of pollen. The two pollens which most commonly 
induce hay fever are timothy pollen in the spring and ragweed pollen 
in the early autumn, although it is possible for a patient to suffer 
from timothy hay fever late in the season and ragweed hay fever 
earlier than the usual time in August or a combination of both. 

It is essential to determine which pollen is responsible for the 
symptoms. If timothy pollen is responsible, the use of its extract 
is indicated, and if ragweed pollen is the cause of the disease, rag- 
weed pollen extract is to be used. In cases in which the symptoms 
persist and are probably due to both pollens, an extract composed 
of both of them may be employed. 

The extracts come on the market in three strengths expressed in 
units, viz.: 10 units, 100 units, and 1000 units to each cc accom- 
panied by a fourth bottle containing a diluent salt solution whereby 
small quantities of the extracts can be prepared for use. The unit 
is an arbitrary one and is that quantity of pollen toxin that can 
be extracted from the thousandth part of a milligram of phleum 
pollen. The object of having these different strengths is to enable 
the physician to determine the dose which should be given as a 
prophylactic or curative measure. The physician must determine 
not only if the patient gives the reaction but also how small a dose 
will accomplish this result. Half a cubic centimeter of Extract No. 1, 
containing 10 units, is drawn up into a syringe, such as is used for 
the injection of tuberculin, and this is diluted by filling the syringe 
from the bottle marked diluent. This solution now represents 5 
units. If the intradermic test is to be used, one or two drops of 
this solution is injected into the skin, not under it, and if the spot 
injected becomes in about five minutes a raised patch, white in the 
center but with a red areola, and lasts for a half-hour or hour, it is 
considered that the reaction is positive to that particular pollen and 
its further use is indicated to protect or cure. Another test is to 
scarify the skin of the arm, as in vaccination, and apply a drop of 
the prepared solution to the spot, rubbing it in well, when a similar 
reaction develops in susceptible patients. If these weak tests fail, 
0.2 cc of 100-unit extract is diluted to 1 cc and employed in the same 



REST CURE 631 

manner, or as a stronger test 0.3 cc of 1000-unit extract is diluted to 
1 cc. If one pollen extract fails, the other should be tested. 

Having determined the strength of the solution needed to induce 
a reaction the physician, if he is giving prophylactic treatment, 
then injects hypodermically one-third of a cubic centimeter (0.3) 
of the particular solution and repeats the injection every three 
or four days according to the severity of the reaction at the spot 
injected, increasing the dose at each treatment so that by the fifth 
injection the patient receives 1 cc of the 10-unit extract. At the 
sixth injection 0.2 cc of the 100-unit extract is used and at the 
tenth treatment 1 cc of it is given. The eleventh injection, provided 
the previous local reactions are not too severe, consists in using 0.2 cc 
of the 1000-unit extract, and the fifteenth consists in injecting 1 cc of 
this the strongest extract. These quantities of extract should be 
used without diluting them. 

The treatment, as already stated, is both prophylactic and cura- 
tive. The first dose for prophylaxis should, if possible, be used at 
least one month before the expected onset of the disease. When 
used to treat hay fever already present, the physician must first 
determine the smallest amount of diluted extract that will cause 
reaction and then begin with one-tenth of this amount and gradually 
increase the doses as above, being governed by the severity of the 
reactions, which often consists in marked itching and burning at 
the site of the puncture. Care should be exercised not to give an 
injection anywhere near the site of a former puncture. When it is 
believed that more than one pollen is responsible for the attack, a 
combined extract is used. 

The results obtained have been good in a sufficiently large number 
of cases to justify the employment of this plan in those who suffer 
from hay fever. The treatment usually has to be repeated every year 
to give relief, and extracts of all the pollens capable of causing hay 
fever are not to be had except in combination on the same principle 
as a multiple vaccine. 

REST CURE. 

The rest cure, so called, is a method devised and elaborated by 
Dr. S. Weir Mitchell, of Philadelphia, for the relief of a large class 
of patients who, for various reasons, are generally ailing from appar- 
ently no organic disease, and yet whose condition is often so alarming 
as to lead to the belief that some hidden cause of a severe train 
of symptoms must be present. In many such instances a careful 
study of the case will show that there is a cause, near or remote, 
which has exhausted the patient's vital forces without producing 
anything else than functional disturbances of the body. Thus a 
prolonged nerve-strain in nursing a sick relative may so exhaust 
the strength of a hitherto healthy woman as to produce hysteria, 



632 REMEDIAL MEASURES OTHER THAN DRUGS 

anemia, and great disturbances of nutrition, or, in another instance, 
cause neuralgia, disordered menstruation, and uterine or ovarian 
pain. In males, mental, sexual, or physical vigor may be impaired, 
owing to prolonged anxiety in business. Be the symptoms what 
they may, as long as they are dependent upon nerve-strain, this 
"cure" is to be resorted to, and if properly carried out is often 
attended with surprising results. It is also a valuable means of 
treating functional and organic heart disease. Before describing the 
method in detail it is proper to state that its entire rationale rests 
upon the remembrance that every movement is an expenditure of 
force, and that a system which has already overdrawn its reserve 
fund of strength must be as careful with its funds that remain as a 
bank should be under the same circumstances. 

It having been decided that the rest cure is to be employed, the 
directions are given as follows: 

A bright, airy, easily cleaned, and comfortable room is to be 
selected, and adjoining it, if possible, should be a smaller one for an 
attendant or nurse. The patient is put to bed and kept there for 
from three to six weeks, or longer, as may be necessary, and during 
this time is allowed to see no one except the nurse and the doctor, 
since the presence of friends requires conversation and mental effort. 
The patient in severe cases must be fed by the nurse in order to 
avoid the expenditure of the force required in the movement of the 
arms. No sitting up in bed is allowed, and if any reading is done 
it must be done by the nurse, who can read aloud for an hour a day. 

In the case of women the hair should be dressed by the nurse to 
avoid any physical effort on the part of the patient. 

To take the place of ordinary exercise two measures are employed, 
the first of which is massage or rubbing of the body, the second 
electricity. By the kneading and rubbing of the muscles and skin 
the liquids in the tissues are absorbed and poured into the lymph- 
spaces and a healthy blush is brought to the skin. This passive 
exercise is performed in the morning or afternoon, and should last 
for from a half to one hour, every part of the body being kneaded, 
even the face and scalp. In the afternoon or morning the various 
muscles should be passively exercised by electricity, each muscle 
being made to contract by the application of the poles of the battery 
to its motor points, the slowly interrupted current being used. 
Neither of these forms of exercise call for any expenditure of nerve- 
force, though they keep up the general nutrition. The following 
programme for a day's existence is an example of what the physician 
should order: 

7.30 a.m. Glass of hot or cold milk, predigested, boiled, or raw, 
as the case requires. 

8 a.m. The nurse is to sponge the patient with tepid water or 
with cold and hot water alternately, to stimulate the skin and cir- 
culation, the body being well wrapped in a blanket, except the leg 



TRANSFUSION 633 

or portion which is being bathed. After this the nurse should dry 
the part last wetted with a rough towel, using some friction to 
stimulate the skin. 

8.30 a.m. Breakfast. Boiled, poached, or scrambled eggs, milk 
toast, water toast, or a finely cut piece of a mutton-chop or chicken . 

10 a.m. Massage. 

11 a.m. A glass of milk, or a milk-punch, or egg-nog. 

12 m. Reading for an hour. 

1 p.m. Dinner. Small piece of steak, rare roast beef, consomme 
soup, mutton broth, and any one of the easily digested vegetables 
well cooked. 

3 p.m. Electricity. 

4.30 p.m. A glass of milk, or milk-punch, or egg-nog. 

6.30 p.m. Supper. This should be very plain, no tea or coffee, 
but toast and butter, milk, curds and whey, or a plain custard. 

9.30 p.m. A glass of milk or milk-punch. 

In this way the day is well filled, and the time does not drag so 
heavily as would be thought. If the stomach rebels at overfeeding, 
the amounts of food must be cut down, but when all the effort of 
the body is concentrated on respiration, circulation, and digestion 
a large amount of nourishment can be assimilated by the exhausted 
body, which before this treatment is undertaken may have had its 
resources so shattered as to be unable to carry out any physiological 
act perfectly. 

For the treatment to be successful the rules laid down should be 
rigidly followed, and the cure should last from three to six weeks 
or longer. 

TRANSFUSION. 

The term transfusion is used in medicine to signify the transfer of 
blood from one person to another, whereas an intravenous injection 
is one in which other fluids than the blood are introduced into the 
vascular system. (See Intravenous Injections.) Transfusion is 
indicated in the following conditions: 

1. Anemia of a severe degree due to acute hemorrhage arising 
from any cause. 

2. In severe anemia arising from a prolonged loss of blood from 
any lesion. 

3. In cases of severe anemia induced by hemorrhage depending 
upon hemophilia or blood dyscrasia when the donor's blood not only 
supplies normal blood but the element which will induce proper 
coagulation. 

4. In pernicious anemia for temporary relief and to prolong the 
life of the patient. 

There are four difficulties which stand in its way. 
1. To find a donor. 



634 REMEDIAL MEASURES OTHER THAN DRUGS 

2. To find a donor whose blood will be compatible with that of the 
donee. 

3. The prevention of clotting during the transference. 

4. The difficulty of dealing with the vessels of the donee, which 
vessels are often collapsed, very easily torn, or buried in fat. When 
this is the case the vein should be exposed by an incision. 

The first difficulty is overcome by friendship or cash. The second 
by testing the blood of the prospective donor until one is found 
which is compatible. The third by the use of a paraffin covering 
of the cannulse employed, or by the mixing of the blood with some 
anti-coagulant, such as sodium citrate solution. The fourth by 
technical skill and the choice of suitable bloodvessels in a given 
case. 

The blood of the donor should also be tested by the method of 
Wassermann to exclude syphilis; any statement of the donor as to 
his freedom from syphilis being liable to error, particularly in the 
case of paid donors. 

Various investigators have found that the blood serum of one 
person may cause the agglutination of the blood cells of another 
person. This agglutination produces serious immediate effects and 
nullifies the good effect of the transfusion. It has been found that 
the blood of human beings is capable of being put in four groups. (Moss.) 
The blood of a given group is compatible with the blood of its own 
group, but in Group I the corpuscles of the donor are agglutinated 
by the blood serum of persons in Groups II, III and IV. The cor- 
puscles of the donor in Group II are agglutinated by the serums of 
persons in Groups III and IV and those of Group III by the serums 
of persons in Groups II and IV. The corpuscles of the donor in 
Group IV are not agglutinated by the serum of any group and for 
this reason persons belonging in Group IV are said to be "universal 
donors," that is capable of being used in any case. 

It will be observed, however, that in all these instances we have 
endeavored to determine if the corpuscles of the donor are compat- 
ible with the serum of the donee, and while it is true that such tests 
are usually adequate probably because the amount of the donor's 
serum is too small to affect the corpuscles of the donee, nevertheless 
it does not follow that the corpuscles of the donee will not be affected 
by the serum of the donor, and, therefore, to be perfectly safe it is 
well to reverse the proposition. The serum of Group I does not 
agglutinate the corpuscles of any other group, and, therefore, they may 
receive blood from any donor. Group I persons are, therefore, said 
to belong to the group of "universal recipients." The serum of 
Group II agglutinates the corpuscles of Groups I and III and that 
of Group III the corpuscles of Groups I and II. That of Group IV 
agglutinates the corpuscles of Groups I, II and III. 

These facts may be summarized as follows for practical purposes: 

Individuals of Group I may receive blood from others in their own 



TRANSFUSION 635 

group and in all other groups but they can act as donors only in 
their own group. 

Individuals of Group II may receive blood from their own group 
and Group IV, and be donors in their own group and to those in 
Group I. Individuals in Group III may receive blood from their 
own group or Group IV and give blood to members of their own 
group and Group I. Those in Group IV may receive blood from 
their own group but they may give blood to all groups. To deter- 
mine the. compatibility of the blood of the donor and donee. It is 
necessary first to ascertain whether they are of the same group. The 
following macroscopic method may be used: 

Place a drop of known Group II serum on a glass slide and mix 
about a third of a drop of blood with the serum. Similarly mix a drop 
of known Group III serum with a third of a drop of the same blood. 
If a brick-dust appearance or agglutination develops in both sera, 
the prospective donor belongs to Group I. If no agglutination takes 
place in either sera, he belongs to Group IV. If agglutination occurs 
in serum II and not in III, he belongs to Group III. If agglutination 
occurs in serum III and not in II, he belongs to Group II. Having 
now determined that the donor and donee are of the same group, it 
is next necessary to test the blood of the donee directly against that 
of the prospective donor. 

The following method devised by Unger may be resorted to: 

In a pipette such as is used for counting white cells, one part of a 
10 per cent, sodium citrate solution and 10 parts of the patient's 
blood are mixed. The same procedure with another pipette is 
followed with the blood of the donor. Nine parts of the fluid in the 
patient's pipette are mixed with one part of the donor's fluid and one 
part of the patient's mixture is mixed with nine parts of the donor's 
fluid. A drop of each one of these mixtures is placed on a slide and 
a drop of normal salt solution added. A cover-glass is then placed in 
position and the slides put under microscopes. Any clumping, that 
is agglutination, on either slide will show that the blood of the donor 
and patient is not compatible, whereas if agglutination does not occur 
the donor is suitable in every respect for the donee, and vice versa. 
Rouleaux formation may be ignored. Clumping, if it is going to 
occur, is usually immediate, but it is best to wait fifteen minutes 
before a final decision is reached. 

When life is in danger from an acute hemorrhage and a donor of 
the same type cannot be had in time it is proper to inject from 10 
to 30 cc of blood and if no irritating or respiratory disturbance takes 
place after ten minutes to proceed as if the type was established. 

If the question of subsequent transfusions be considered at a 
later date it is proper to make the agglutination test a second time, 
even when the same donor is employed, and if ten days to two weeks 
have elapsed the danger of anaphylaxis is to be considered. This 
can be avoided by the earlier use of each subsequent injection and 
by Besredka's test described in the article on Antitoxin. 



636 REMEDIAL MEASURES OTHER THAN DRUGS 

It is becoming increasingly evident that the simplest method 
of transfusion is the best. This is that of Lindeman, which, how- 
ever, requires two assistants. It consists in having several 20 cc 
Record syringes with suitable needles. These needles are in reality 
small cannulas with a trocar having a sharp bevelled point so that 
the wall of the vein is readily punctured. The needles are coated 
with sterile liquid albolene by drawing up and expelling the oil, 
using an extra syringe to thoroughly clear the needles of any excess 
of the oil. 

Three basins of sterile saline are placed on a table between the 
donor and donee. A trocar and cannula is now introduced into the 
vein of the donor and the trocar is withdrawn so that its sharp point 
does not further wound the vein. Blood at once appears and a 
syringe filled with normal saline is attached so that the blood is 
driven back from the cannula, the syringe remaining in place until 
the donee is ready. The same procedure is followed as to the donee 
by the operator or his assistant. A fresh empty syringe is now 
attached to the cannula of the donor and filled with blood and it 
is handed to the assistant who injects its contents into the vein of 
the donee while the chief is filling a fresh syringe handed him by 
the nurse. After the assistant has emptied his syringe he hands 
it to the nurse who washes it in the three basins of saline so that 
all residual blood is removed before she hands it as a fresh syringe 
to the chief for a new load of blood. The syringe should be so well 
washed that the saline solution in the third basin is not discolored. 
These procedures are continued until sufficient blood is transfused. 
If the donee begins to cough or complains of a sense of oppression 
after 200 cc have been injected, the transfusion should be stopped 
at once as these are signs of hypertransfusion. The quantity used 
varies with the needs and size of the patient. Usually from 60 
to 150 cc are used for infants and from 500 to 1000 cc for adults. 
Lindeman states he has done this many hundred times without any 
but good results. 

When the patient is restless it is best to expose the vein, nick it 
with scissors and use a cannula which. fits the syringe and has a 
shoulder to hold it in the vein by the tying of a ligature. In infants 
it is almost impossible to use a vein in the arm. The needle in such 
cases should be passed into the great saphenous vein just in front of 
the internal malleolus. If it cannot be felt or seen it is easily exposed 
by an incision. In very young children the longitudinal sinus in the 
middle line at the posterior extremity of the fontanelle may be used. 

A very much simpler plan possessing the advantage that the 
blood can be taken from the donor at one place and carried almost 
any distance to the donee is the so-called citrate method. A glass 
flask or beaker capable of holding up to 500 cc is charged with 
25 cc of a 2 per cent, sterile solution of sodium citrate. A tourni- 
quet is now placed on the donor's arm to cause venous congestion 
and a large caliber needle is introduced into a vein at the elbow 



TRANSFUSION 637 

toward the hand. As the blood flows into the glass container it is 
gently mixed by means of a glass rod with the solution of sodium 
citrate, and when 250 cc are present 25 cc more of the 2 per cent, 
solution are added if a total of 500 cc of blood are to be taken. The 
object in dividing the total quantity of 50 cc of sodium solution 
being to prevent the first amounts of blood being exposed to too 
much citrate of sodium. The intent is to have the blood when 
the drawing is completed contain sodium citrate solution in a dilu- 
tion of 0.2 per cent, the amount needful to prevent coagulation and 
no more. Another needle having been introduced into the vein of 
the donee, toward the shoulder, normal salt solution is poured into a 
funnel, or the barrel of a syringe, attached to a rubber tube through 
which the salt solution is allowed to run for a moment to drive 
out any air. The tube is then attached to the needle or cannula in 
the arm and before all the salt solution leaves the funnel the blood- 
mixture, if free from clots, is poured in. (See Intravenous Injection.) 

A better method is that by which an ordinary Erlenmeyer flask 
is fitted with a cork through which are passed three glass tubes, 
two of which are short and one long enough to reach nearly to the 
bottom and bending toward the side of the flask. A rubber tube 
armed with a large needle is attached to one short tube. Another 
rubber tube is attached to the second short tube and its distal end 
to the suction, or vacuum, nozzle of a pump such as is used to pro- 
duce a vacuum in an aspiration apparatus. A third rubber tube is 
attached to the external end of the long glass tube and it is armed 
at its distal end by a second needle and clamped. Sodium citrate 
solution is placed in a sterile beaker, the first needle is immersed in 
it and the suction pump is put in play. This puts the citrate solu- 
tion in the flask and tests the efficiency of the apparatus. Just 
before the last part of the citrate solution is about to be sucked up 
clamp the rubber tube above the needle. Then push the needle 
into the donor's vein and immediately remove the clamp so that the 
vacuum in the flask can draw the blood. The vacuum is maintained 
by use of the pump. Gently rotate or shake the flask to thoroughly 
mix its contents while the blood is flowing. When the amount 
drawn is adequate, say 500 cc, apply the clamp to the donor's tube once 
more. Change the pump so that the output nozzle is inserted into 
the same tube as has been occupied by the suction nozzle. Remove 
the clamp on the rubber tube, which is attached to the long glass tube 
and pump in air until the fluid flows from the tip of the second or 
donee's needle. Again clamp for a moment while the needle is 
inserted in the vein, thus remove the clamp and keep the citrated 
blood flowing by producing a positive pressure with the pump. 

The container of the blood should be kept warm, or, if the blood 
is to be carried some distance, the citrated blood should be warmed 
before it is injected by immersion in hot water, so that its tempera- 
ture in the injecting flask is about 110° F. The citrate method is 
more prone to produce a chill and febrile reaction than the pure blood 



638 REMEDIAL MEASURES OTHER THAN DRUGS 

method, and so is not so safe in those who are exhausted by disease 
or who are in a grave condition as the result of prolonged bleeding 
as for example in cases of profuse uterine hemorrhage. 

The amount of blood taken from a donor should not exceed 600 
cc at one bleeding. 

All methods of transfusion are prone to be followed by more or 
less reaction, but the use of pure blood produces severe reaction less 
frequently than the citrate method. A chill followed by fever, begin- 
ning about two or three hours after injection, may be as high as 
102° or 104° and may last eight to twelve hours. Urticaria is not 
uncommon as a sequel. 

VACCINE-THERAPY. 

Vaccine-therapy consists in the injection into the subcutaneous 
tissues of dead germs identical with those living germs inducing the 
disease; the introduction of living germs being dangerous for obvious 
reasons. 

The term vaccine-therapy is a misnomer, in that it conveys the 
idea that the method of cure consists in treating the patient by 
scarifying the skin and inoculating the patient with living germs, 
as in the process by which we immunize a person to small-pox by 
means of cow-pox virus. It is also a misnomer because it leads to 
the belief that some part of the process has to do with a calf or 
cow ("vacca," a cow), when, as a matter of fact, this animal is not 
even remotely connected with it. Again, it is a misnomer because, 
as a rule, dead germs are inoculated. A better term would be 
inoculation-therapy, but the phrase vaccine-therapy is so well 
established that it has probably come to stay. 

It is absolutely essential that the germs used, or the toxins used, 
be of the same kind as the organism already producing the abnormal 
state, and not only must the organism be of the same kind, but often 
of the same strain if it is to be effective. Because the introduction 
of these germs renders the already present invaders susceptible to 
phagocytosis, or, in other words, makes them fit to be devoured, it 
is said that opsonins are developed in the blood, or tissues, from 
the Greek word ottgovlv, "I cater for," or "I prepare food," and 
for this reason vaccine-therapy is often correctly termed "opsono- 
therapy." 

Physiological Action.— Among the vital processes by which the 
body protects itself from invading microorganisms is phagocytosis, 
or the swallowing and destruction of germs by those white blood- 
cells which possess this function as a result of which they are called 
phagocytes. If the body is in health and the invading army of 
germs is not too large or too virulent, so many of the invaders are 
overcome by this and other protective measures that illness does 
not occur, or, if it does, recovery ensues. Conversely, if the phago- 
cytes are not up to their work, illness and death may ensue. 



VA CCINE- THERA PY 639 

When a suspension of dead bacteria in sterile normal salt solution 
is injected subcutaneously or intramuscularly, certain definite pro- 
cesses ensue. The body contains in its cells and juices a ferment or 
substance which possesses the power of dissolving bacteria. This 
complement cannot act, however, without the aid of another factor 
called an amboceptor, which serves to connect or link the complement 
to the bacterium. The amboceptor is produced by the body as a 
result of the injection (Effect 1). When it links the complement to 
the bacterium the latter is dissolved or disintegrated (lysis) (Effect 
2), and the poison in the cell is set free (Effect 3). This poison 
develops a factor (opsonin) (Effect 4) which renders the living 
bacteria in the body susceptible to the attacks of the phagocytes 
(Effect 5). The phagocytes devouring the bacteria set free their 
poison (Effect 6), and this poison in turn produces more opsonin 
(Effect 7). This poison also induces the development of additional 
protective measures, namely, the appearance of increased bacteri- 
olytic power (Effect 8) and, again, it stimulates the production of 
antitoxin (Effect 9). 

An examination of the phagocytes, when brought into the pres- 
ence of the infecting germ under the microscope, shows that at first 
their ability to destroy the invaders is somewhat decreased, and 
this is called the "negative phase;" but later they rally, the germs 
are rendered more susceptible, and phagocytosis is very active— 
the "positive phase." It is, therefore, evident that for the accu- 
rate application of vaccine-therapy the physician must be skilful 
in the examination of the blood and in bacteriological methods, that 
he may study phagocytosis and differentiate and then cultivate the 
specific germ which is causing the infection. Furthermore, it has 
been found that the skill to determine opsonic activity is so great 
that even those who work at it constantly often fail to get accurate 
results. For this reason accurate vaccine-therapy is limited to those 
who are so situated that a competent bacteriologist and opsonic 
estimator is at hand to assist. The result is that accurate or precise 
methods have to be cast aside in many cases, the physician sending 
a specimen to a laboratory to have the kind of infecting organism 
determined, and then injecting into the patient a "stock vaccine," 
that is, one put up by dealers in biological products, or he waits 
until the bacteriologist not only determines the germ, but grows it 
by cultural methods, and provides the physician with what is called 
an "autogenous vaccine;" that is, one made from the patient's own 
germs. The number of dead organisms in a given quantity of salt 
solution is stated on the label, and the dose is gauged by this means 
(see Dosage). 

It is evident, from what has been said above, that at the best 
this plan of treatment is open to many chances of failure, and it 
is also to be borne in mind that if the patient is in a state of very 
low vitality because of the existing infection, or because of an ante- 



640 REMEDIAL MEASURES OTHER THAN DRUGS 

cedent illness, he may be damaged by an injection, because the 
"negative phase," or period of decreased phagocytic activity, may 
be exaggerated, and the "positive phase," or increase in phago- 
cytosis, may never occur. In other words, we push the drowning 
man under water instead of stimulating him to increased effort 
to save himself. In the presence of very grave infectious illness, 
therefore, vaccine-therapy is not permissible unless a competent 
worker in opsonic estimation is able to assure us that the tissues 
of the body are capable of preparing the germs for phagocytosis. 

There is, therefore, a marked difference between vaccine-therapy 
and serum-therapy. In the former we stimulate the body to develop 
substances with which to aid in its protection; in the latter, we 
give the body antitoxic substances already prepared by another 
and healthier animal. Furthermore, it commonly happens that the 
patient is infected not only by one organism, but different strains 
of that organism, or by a number of different microorganisms. It, 
therefore, becomes necessary to employ a vaccine that represents 
all the strains or kinds present. When only one strain is present 
it is called a univalent vaccine, when more than one strain is used 
it is called a polyvalent vaccine, and when the vaccine is composed 
of more than one organism it is called a "mixed vaccine." Because 
of lack of laboratory facilities physicians often use a mixed or a 
polyvalent vaccine in the hope of hitting the offending germs, as 
in the old "shot-gun" prescription. They also are often forced to 
use stock vaccines for the same reasons, and while this cannot be 
considered accurate, it is the best thing that can be done in many 
instances. In any event the kind of germ causing the illness must 
be determined, as otherwise the treatment is futile and may be even 
harmful. Then, too, it is to be recalled that in most cases there are 
infections associated with the main infection, and this justifies the 
use of a mixed vaccine if the associated germs are isolated with the 
chief agent. This is notably the case in acute catarrhal conditions 
of the mucous membranes of the upper respiratory tract. In these 
states a multiple mixed vaccine is employed, containing as its chief 
agent the staphylococcus, with the streptococcus, pneumococcus, 
the micrococcus catarrhalis, the bacillus of Friedlander, and the 
bacillus of epidemic influenza. Few persons are willing to submit 
to prophylactic injections to prevent colds, and after a cold is begun 
the use of such a vaccine seldom cures in less time than is usually 
consumed in getting well. 

Without doubt those infections due to the staphylococcus pyo- 
genes aureus and albus are the ones which yield best to vaccine- 
therapy. As, for example, certain types of acne pustulosa and 
furunculosis, wound infections, cellulitis, and abscess in the subcu- 
taneous tissues. If the acne is due to the bacillus acne, that specific 
vaccine must be used. 

When the infectious process is due to streptococci the results of 



VA CCINE-THERA PY 641 

vaccine-therapy are often disappointing, perhaps because this 
microorganism occurs in many different strains. The best results 
have been obtained from the use of autogenous antistreptococcus 
vaccine in puerperal sepsis, and in localized or limited infections 
rather than in widespread infection of the entire system. Neverthe- 
less, in erysipelas, which is a local and general infection by the 
streptococcus, the plan of treatment nearly always fails. 

In pneumococcus infections the results are fair if the treatment is 
used carefully. It gives less good results in pneumonia than in 
localized pneumococcic infections elsewhere than in the lung. 

In typhoid fever vaccine-therapy may modify the severity of 
the disease, but it does not shorten its duration. 

In infections by the Bacillus coli, as in the kidneys and bladder, 
vaccine-therapy often gives excellent results, and in all forms of 
gonococcus infection save in acute gonorrheal urethritis it is often 
very effective. (See also Antigonococcic Serum.) 

Dosage.— This differs in different infections and in different cases. 
Unlike antitoxic serum, which should be in large dose in direct 
proportion to the gravity of the illness, vaccines, when they are 
first used, have to be given in inverse ratio to the gravity of the 
illness for reasons already stated. A high fever contraindicates 
their use. 

Having determined the kind of infection, the general state of the 
patient should be considered and, if possible, his "opsonic index" 1 
determined. If he is very feeble, the early doses should be very 
moderate, and if he appears worse after their use the size of the 
dose must be decreased. 

In general terms the doses of the several vaccines for curative 
purposes are approximately as follows: 

Staphylococcus .... 100,000,000 to 1,000,000,000 at a dose. 

Streptococcus 5,000,000 to 200,000,000 at a dose. 

Gonococcus 5,000,000 to 500,000,000 at a dose. 

Bacillus coli 10,000,000 to 200,000,000 at a dose. 

The dose is given according to need ; that is, only when the phago- 
cytic power, after its increase, is on the wane; if the opsonic index 
cannot be had, then as soon as the patient fails to continue to 
improve. Very rarely are the doses given oftener than every day, 
usually every second or third day. The dose is increased only 
when the dose previously given fails to produce increased phago- 
cytic power or the patient fails to get better. If he is very ill, they 
should be reduced or they may overwhelm him. The more acute 
the illness, the less of the dose. If the reaction consists in a chill, 
vomiting and collapse, the dose is far too large. 

1 The opsonic index is the difference between the ability of the phagocytes of the 
patient and the phagocytes of a healthy person to destroy, or consume, a number of 
the specific organisms present in a given time. 
41 



642 REMEDIAL MEASURES OTHER THAN DRUGS 

In gonorrheal infection the dose is repeated about every four 
or five days. When pertussis vaccine is employed the dose should 
not be repeated in less than five days. It seems to do better as a 
prophylaxis than as a cure. 

In all cases the injection is given in some part of the body not 
well endowed with sensation, yet well supplied with vessels and 
lymphatics, as the belly wall or back. Intravenous injections are 
not used because they may overwhelm the patient, and there is 
reason to believe that the specific substance is produced locally in 
the tissues and carried away by the blood or lymph stream. Indeed, 
it has been suggested that the best results will follow several small 
injections, in different areas, at one time, than when one single 
large dose is given in one place, since several foci for the production 
of complement or other useful substances will thereby be established. 

Prophylactic vaccine-therapy is carried out to protect persons who 
may be, or have been, exposed to certain common infectious diseases. 
Thus, typhoid fever can be entirely prevented in armies and in 
hospital attendants by this means. The dose injected is about 
500,000,000 followed in seven days by another dose of 500,000,000, 
and a week later by another dose of 1,000,000,000. The best point 
for injection is in the loose tissues below the clavicle or into the 
outer aspect of the arm, not intramuscularly. In less than twelve 
hours a local reaction develops and nearby lymph nodes may become 
swollen. No general symptoms may develop, but commonly a 
slight febrile movement and languor, lasting for a day after the 
first dose, is produced. For these reasons in civilian practice it 
is better to give the dose on Saturday afternoon so that the effects 
will be off before the need of going to work arises. Active exercise 
is to be avoided for twenty-four hours. Antityphoid vaccine is 
contraindicated in the weak and feeble, in menstruating women, 
and in the presence of any febrile process. When used the individual 
must abstain from all alcoholic drinks. Typhoid vaccine is not 
curative. 

In order to protect not only against typhoid fever but against the 
paratyphoid bacillus A and B, a vaccine made up of 500,000,000 
typhoid bacilli and 250,000,000 each of the paratyphoid type is now 
generally used in order to protect against all these infections. ' 

When antityphoid inoculation is given a child between seven and 
twelve years, one-quarter of adult dose is used, one-half from twelve 
to fifteen years, and two-thirds from fifteen to eighteen years. For 
prophylactic purposes ordinary vaccines are best, but if vaccines are 
used to combat typhoid fever already developed it would seem best 
to use sensitized vaccines. (See below.) 

Scarlet fever has been prevented by streptococcus vaccine, but 
the statistics are, as yet, uncertain. 

All these vaccines are now placed on the market in glass bulbs or 
in syringe containers ready for immediate use. The syringe con- 



VACCINE-THERAPY 643 

tainer is the best form, as the barrel is so marked that any dose 
less than its full contents can be measured by pressing on the piston 
without exposing the contents. When a large number of persons 
are to be treated, as in the use of antityphoid vaccination, the sus- 
pension of bacilli is kept in a sterile bottle covered with a rubber 
diaphragm, through which the needle of a hypodermic needle is 
plunged and the dose of suspension withdrawn. 

Lipo-vaccines differ from ordinary vaccines in that the organisms 
are suspended in oil instead of salt solution. Because of the oil the 
entrance of the active ingredient of the germs into the general sys- 
tem is slower and for this reason their immediate effects are not 
so sure but larger doses can be given at one treatment. 

Sensitized Vaccine.— Sensitized vaccine is one in which the specific 
bacteria producing a disease have been brought in contact with and 
have absorbed, or united with, antitoxin produced in an animal by 
the introduction into its body of the toxin of the same microorgan- 
ism. This immune serum is identical in its effect with that of the 
amboceptor already described, and therefore the body of the patient 
does not have to produce an amboceptor before the complement 
can begin its process of dissolving the germ. It is to be understood, 
however, that the use of a sensitized vaccine is not equivalent to 
the use of vaccine treatment plus antitoxin treatment. 

It has been proposed to use living sensitized bacteria on the 
ground that as they are sensitized the tissues can attack and destroy 
them before they can multiply sufficiently to do harm. So far, 
however, this is considered dangerous because, unless the sensitiza- 
tion is so nicely adjusted that the protective processes can act at 
once, the patient may have added to his old infection a new infection. 

The advantages of sensitized vaccines over ordinary vaccines 
consist in the following points, so far as we can tell from experiments 
on animals and limited tests on man. 

(a) They cause little or no reaction or inflammation at the point 
of infection. 

(b) They are less prone to produce systemic symptoms, such as 
fever and general wretchedness, although the exact reason for this 
is not very clear. 

(c) Because of (b) they can be given in large doses and more 
frequently. 

(d) They develop immunity or protection more rapidly. 

(e) Because of (6) they can be used in cases in which the illness 
is more severe without so much danger of the "negative phase" 
being unduly prolonged or so severe that the positive phase is never 
reached. 

The sensitized vaccines possess the disadvantage that the immune 
serum used to sensitize must be produced by exactly the same 
bacterium as that injected and that infecting the patient, in order 
to combine with the bacterium used for injection. If this is not 



644 REMEDIAL MEASURES OTHER THAN DRUGS 

the case the injection is no better than ordinary vaccine. In acute 
illness there is not time, as a rule, to prepare even an autogenous 
vaccine, still less to make immune serum. In other words, in most 
instances, we use a " stock sensitized" vaccine, so-called, hoping that 
it has been provided with the proper amboceptor. 

For the reasons just given, the doses of sensitized vaccine are, 
theoretically, considerably in excess of ordinary vaccines, but it 
is safer to begin with ordinary vaccine doses and increase rapidly 
if no reaction ensues. 

Vaccine-therapy has not stood the test of clinical and laboratory 
investigation as well as it was hoped it would. At times it seems 
to give excellent results in an individual case and, again, utterly 
fails. In some instances this is due to the use of a different strain 
of organism from that inducing the disease, to the presence of mixed 
infection, or to the dose being too small to do good or so large as to 
decrease rather than increase vital resistance. In other words, the 
primary negative phase may be too severe and the patient never 
gets the secondary positive phase or benefit. While on the one hand 
autogenous vaccines seem to give the best results, on the other 
hand it has been shown that the injection of any foreign protein or 
toxin may seemingly cause such an arousing of the vital processes 
as to result in cure. When two large series of cases of a given disease 
are tested, one with vaccine and one without, and every element 
of fallacy which can be excluded is excluded it frequently happens 
that the non-vaccine cases show a better percentage of recoveries 
than those receiving vaccine. The writer believes that the field of 
efficiency of so-called vaccines in treatment, in distinction from 
prophylaxis, is constantly narrowing and that before long this plan 
of treatment may be perhaps considered obsolete except in very local- 
ized infections. Nevertheless so many observers claim good results 
from vaccines that the text of the preceding pages appears out of 
respect for their views rather than because the author has faith in the 
measures advised. These pessimistic remarks deal with the vaccine 
treatment of infections already developed; and not with prophylaxis 
by vaccines to prevent typhoid fever. 



VENESECTION. 

Bleeding, or phlebotomy, is so rarely practised to-day that very 
many of the profession have never abstracted blood for therapeutic 
purposes or have even seen it done by someone else. Furthermore, 
it is to be feared that many of the younger physicians would hardly 
know how to bleed if called upon to do so at a crisis. All this is 
wrong, for bleeding is a measure undoubtedly of the greatest value, 
and one which every physician may be called upon to resort to. 
Like many therapeutic measures, it was sadly abused in the early 



VENESECTION 645 

part of the last century, and people when taken ill were bled with 
the same regularity that they were put to bed. 

The indications for venesection are as clear and well defined as 
are the indications for any remedy. Briefly stated, we may say 
that all states of the circulatory apparatus denoting high arterial 
tension and acute excitement are indications, and that weakness, 
low arterial tension, and systemic or circulatory depression are 
contraindications, but the chief indication is when there is great 
venous engorgement or turgescence. 

In many cases of disease of the mitral valves with ruptured com- 
pensation and marked turgescence of the great veins, venesection 
gives great relief. This also holds true in pneumonia with venous 
turgescence and in uremia. 

In eclampsia and sunstroke with great cyanosis and venous 
engorgement, venesection may save life. 

In apoplexy the extravasation of blood into the brain causes 
great arterial tension, and free venesection has been commonly 
performed to relieve this state. Recent studies by Gushing, how- 
ever, indicate that bleeding under those conditions is contraindicated. 
(See Apoplexy.) 

The method by which venesection is practised is yet to be described. 
It is a very simple operation if an assistant is present to make pressure 
on the vein or entire arm. Often this pressure is best exercised by 
means of the cuff of a sphygmomanometer apparatus or a handker- 
chief or bandage tightly twisted about the arm above the spot where 
the wound is to be made. Under these circumstances the veins of 
the arm become prominent and distended. Many physicians bleed 
by pushing a large hollow needle or cannula through the skin into 
the distended vein toward the hand. If, however, the veins are small 
or buried in fat one of them may be readily bared by a short longi- 
tudinal incision of half an inch, the fascia being separated until the 
glistening blue surface of the vessel appears free from fat or connec- 
tive tissue. Into this vessel, with the edge of the knife turned up- 
ward, a small longitudinal incision is made, care being taken that 
the point of the blade is not driven in far enough to injure the pos- 
terior wall of the vein, or a sharp-pointed pair of scissors is used and 
the vessel is snipped on its anterior wall. If a clot forms and stops 
the flow, it must be removed by a piece of aseptic gauze, while if 
the flow is to be stopped, remove the bandage above and apply a 
compress over the incised vein, the compress being held in position 
by a bandage. Care should always be taken that the bandage on 
the upper part of the arm is not so tight as to cut off all blood supply 
to the arteries of the lower part of the limb. 



FEEDING THE SICK. 



In the opening pages of this work the importance of properly 
feeding the sick has already been emphasized. It is manifestly 
impossible for the writer to go into details concerning the deep 
and difficult problems of the changes in the food when taken into 
the body for assimilation. At this point it is necessary only to 
recall that the foods taken by man consist in proteids, carbohydrates, 
and hydrocarbons. In the albuminous or proteid articles of food 
nitrogen is a prominent constituent, and the type is egg-albumin. 
While most nitrogenous foods are animal in source, it must not be 
forgotten that gluten and legumen are nitrogenous and derived from 
vegetables. The carbohydrates consist of substances in which 
carbon, hydrogen, and oxygen are combined, the hydrogen and the 
oxygen in the proportion to form water, of which the types are 
starch, dextrin, cane-sugar, grape-sugar, lactose or milk-sugar. The 
hydrocarbons are composed of carbon, hydrogen, and oxygen, but 
the proportion of oxygen is insufficient to convert all the hydrogen 
into water. The types of this group are butter and other fats. 

The function of the proteid, or albuminous, foods is to contribute 
to the repair and formation of the body tissues, particularly those 
which are nitrogenous; they also contribute to the development of 
muscular and nervous energy and the production of heat, being 
split up into nitrogenous and non-nitrogenous parts, from the last 
of which fat may be formed and deposited or burnt up in the 
development of force. 

The carbohydrates are split up in the body into carbonic acid 
and water, and in this process yield heat and energy. Unlike the 
proteids, they do not enter the tissues of the body unless it be that 
they are converted into fat. By reason of the heat and energy which 
they contribute to the economy they protect the albumins and 
fats from demands which would otherwise be made upon them for 
these purposes. 

The hydrocarbons, or fats, are employed in the body to yield 
force and heat, and are stored up in the form of fat, so as to act 
as a reserve in case of need, so that by their use the albuminous 
portions of the body are saved from demands upon them. For 
these reasons hydrocarbons and carbohydrates can be well taken 
in large quantities by those who take much exercise, but are harmful 
if partaken of largely by persons leading sedentary lives. 
(646) 



FEEDING THE SICK 647 

It is manifest, therefore, that for the maintenance of health we 
must provide a patient, not with nitrogenous or carbohydrate foods 
alone, but with some of all the food articles, regulating the propor- 
tions of each to his needs and his ability to utilize them after they 
are ingested. The practical application of these facts is as follows: 

In fevers, in which there is an active wasting of the tissues of the 
body, we give albuminous foods to replace the tissues destroyed 
or to make up for their loss, and these consist of soups, eggs, milk, 
and the gelatinous substances which, while not very nutritive, are 
what are known as "albumin-sparing" substances. As the secretion 
of the gastric juice is faulty in nearly all fevers, it is important to give 
these foods in semiliquid or liquid form, so that they can be readily 
digested, and we often aid their digestion by the use of pepsin and 
hydrochloric acid. 

- As carbohydrates and hydrocarbons add heat or energy to the 
body, and their combustion protects the albuminous tissues, they 
also must be used, particularly the former. There is no doubt that 
physicians are far too prone to limit the patient's diet to proteids, 
and in the author's practice he invariably prescribes, in addition to 
the proteid foods, thin preparations of starch, such as strained rice, 
strained oatmeal, cracked wheat, corn-starch, and barley, aiding their 
digestion, if need be, with taka-diastase or pancreatin. 

In order that an approximate idea of the proportion of foodstuffs 
may be conveyed to the reader, it may be pointed out that the 
healthy human body must be provided in twenty-four hours with 
that amount of food which will yield his body 3000 calories. 1 This 
is best accomplished by the use of the following proportions, accord- 
ing to Egleston: carbohydrates, 400 grams; fats, 150 grams; proteids, 
150 grams. Nearly all foodstuffs contain the several classes of 
proteids, carbohydrates, and hydrocarbon in varying proportions. 
It is interesting to note how many more calories are provided by 
the carbohydrates and fats than by the proteids, but it is also worthy 
of note that the proteids provide the materials which are useful for 
the repair and growth of tissues. 

The common foods may be measured approximately as follows: 

Grams. Calories. 

1 tablespoonful of oatmeal, equals 40 34 

1 medium-sized white potato, equals 90 90 

1 slice of bread \ inch 5x5, equals 25 80 

1 roll, equals 30 115 

1 large tablespoonful of rice, equals 30 45 

1 tablespoonful of macaroni, equals 35 25 

1 tablespoonful of cooked peas, equals 30 40 

1 tablespoonful of sugar, equals 8 33 

1 medium-sized oyster, equals 15 18 

1 orange (small), equals 150 60 

1 egg, equals 50 70 

1 pat or ball of butter, equals v 8 80 

1 slice lean roast beef \ inch 5x3, equals 60 70 

1 wineglass of whisky, equals 30 85 

1 A calorie is the French unit of heat, or that amount of heat required to raise the 
temperature of one kilogram of water one degree Centigrade. 



64§ FEEDING THE SICK 

As pointed out the normal intake when the patient is active or 
febrile is about 3000 calories, and the nutritional balance is approxi- 
mately maintained by 500 grams of carbohydrate, 150 grams of 
fat and 150 grams of protein. The approximate amounts of foods 
needed in health can be calculated from this table: 

Thus a breakfast of: 



Approximate Approximate Approximate 





carbohydrate. 


protein. 


fat. 


Calories. 




Grams. 


Grams. 


Grams 


210 




48 


7 




160 




12 


7 




140 






13 


5 


160 








16 


'160 




26 






66 




16 






896 cal 


ories 









6 tablespoonfuls of oatmeal, equals 

1 glass of milk, equals 

2 eggs, equals 

2 pats of butter, equals . 
2 slices of bread .... 
2 teaspoonfuls of sugar, equals 



The other meals can easily be figured in the same manner. A 
strict milk diet is impossible without starvation because to get 3000 
calories the patient would have to take between 4 and 5 quarts a 
day. This would overburden his stomach and kidneys and, while 
giving 3000 calories, would contain an excess of protein and fat and 
an inadequate amount of carbohydrate. As this amount cannot 
be taken the patient must to some extent live on himself. If he 
attempts this excess of milk and his kidneys are diseased he is unable 
to get rid of such an excess of liquid and will become dropsical 
unless freely purged. 

Water forms such an important part of the body that its free 
ingestion is advisable, if it is pure, in nearly all cases of disease 
except advanced parenchymatous nephritis. 

Having considered the general theory of feeding, we may now 
proceed to the actual preparation of food for the sick. There are 
several important general facts to be borne in mind in this connection : 

1. The food, when prepared, must be capable of ready assimilation. 

2. It must be, as a rule, fairly concentrated in the sense of contain- 
ing great nutritive power in little bulk, since it is a mistake to weary 
a feeble patient with much swallowing. 

3. It must be easily swallowed. 

4. It must be as attractive to the sight, smell, and taste as possible. 
When milk is given for any length of time its taste should be varied, 
if possible, by the addition of enough coffee, tea, cocoa, or sweeten- 
ing to prevent the patient from taking a dislike to it. Its nutritive 
properties may often be advantageously increased by the addition 
of some of the well-known infant foods; and if it curdles too quickly 
in the stomach, this may be delayed by the use of barley-water in 
equal parts, or lime-water, or by the addition of thin oatmeal gruel 
or strained rice to the milk. Often the addition of salt improves 
the taste and aids its digestion, and its dilution by adding aerated or 
carbonated water from a siphon is also refreshing and aids digestion 



BUTTERMILK AND STARCH 649 

in some instances. In other instances the best results are produced 
by peptonizing the milk (see below). When broths are used, they 
may well be flavored with other things than the meat from which 
they are made. This is easily accomplished by placing in a small 
bag such vegetables as carrot, turnip, celery, parsnip, parsley, thyme, 
etc., and then cooking this bag and its contents with the broth, 
whereby the nutritive properties of the meat and vegetables and the 
flavoring of the latter are given to the soup. 

The following recipes will be found useful in many cases: 

CASEIN MILK. 

This preparation is useful in feeding adults and infants with very 
feeble or disordered digestion. To one quart of fresh milk at 100° F. 
add four teaspoonfuls of essence of pepsin and mix thoroughly. 
After this mixture has stood at 100° F. until it has become curdled 
(this usually occurs in about thirty minutes), filter off the whey 
through a clean linen handkerchief and allow the curd in the hand- 
kerchief to remain suspended until the whey ceases to drop from 
it. The curd is then placed on a fine sieve, through which it is 
pressed by means of a knife-blade or spoon. Add to this curd, 
which has been finely divided by passing through the sieve, one 
pint of water and one pint of buttermilk, which should be less than 
twenty-four hours old. This preparation is practically a form of 
predigested milk and the individual curds are so fine as to be easily 
digested. Depending upon the richness of the milk, one quart of 
this preparation contains a little less than 400 calories, and equals 
about 3 per cent, of proteid, 2.5 per cent, of fat, 1.5 of sugar, and 
0.5 per cent, of salts. When used in cholera infantum the quan- 
tities administered should, at first, be very small and gradually 
increased until the stomach and bowels become tolerant. 

BUTTERMILK AND STARCH. 

Take one quart of fresh buttermilk, and add it gradually to one 
or two tablespoonful of rice flour or wheat flour, stirring constantly 
so as to prevent the formation of lumps. This mixture is now 
heated slowly for a period of fifteen or twenty minutes until it 
reaches the boiling-point, when it is taken from the fire and from 
one to two ounces of sugar are added. It is then placed in a bottle 
which is corked, and placed on ice where it may be preserved for 
a considerable period of time. By the use of sugar the deficiency 
in heat units caused by the abstraction of the butter-fat is com- 
pensated and the addition of the rice flour not only increases the 
heat units but also prevents the formation of tough curds. Such 
a preparation after standing separates into two layers, the upper one 
being composed of the milk serum, and the lower one, containing the 



650 FEEDING THE SICK 

coagulated casein in very fine curds, which are, therefore, ready for 
digestion. The bottle should be shaken to mix these two layers 
before its contents are used. Such a preparation may be given to 
infants in the proportion of 3 to 6 ounces for each 3 pounds of the 
child's body weight per day. Where gastro-intestinal disturbance 
already exists with a passage of undigested curds, the buttermilk 
should be preceded for one or two days by beef juice or rice water 
and then given in gradually increasing quantities. This form of 
buttermilk may also be given to invalid adults as a concentrated, 
easily digested food. (See article on Malt Soup.) 

As much of the buttermilk which is found on the market is not 
fresh, it is often best to prepare it by the use of "Lactone Tablets," 
which contain lactic acid bacilli. The advantage of buttermilk 
prepared by this means is that it contains all its butter-fats, and, 
therefore, has a higher nutritive value than ordinary commercial 
buttermilk. It is essential, however, that the milk shall be fresh 
and that no preservatives, such as formaldehyde, shall have been 
used, since such preservatives prevent the lactic acid bacillus in 
the tablets from acting upon the casein. 

The method of employing lactone tablets is as follows: 

To one quart of fresh milk add one lactone tablet, shaking or 
stirring the fluid so that the crumbled tablet will be thoroughly 
dissolved. After being properly covered the bottle containing the 
milk should stand at the ordinary room temperature of from 70 to 
80 degrees for from twelve to twenty-four hours. The warmer the 
air the shorter the time necessary for the change to take place. 
The bottle containing the milk is than placed in a refrigerator for 
future use. After standing for some time it separates into two 
layers which should be thoroughly stirred until a homogeneous fluid 
is produced before it is used. 

When buttermilk is used not only as a form of food, but also 
for the purpose of getting the effect of the lactic acid bacillus as a 
therapeutic agent, it must be taken when it is not more than twenty- 
four hours old, so as to avoid excessive acidity and in order to obtain 
active bacilli. (See Lactic Acid Bacillus, Part II.) 

PEPTONIZED MILK. 

Take a perfectly clean, clear glass quart bottle and place in it 
one of Parke, Davis & Co.'s peptonizing tablets, or the contents of 
one of Fairchild's peptonizing tubes, and a teacupful of cold water, 
and after shaking pour into the bottle a pint of perfectly fresh, cool 
milk and stir the mixture thoroughly. Next place the bottle con- 
taining the milk in a can of water at such a temperature that the 
whole hand may be submerged in it without pain. If complete 
digestion of the milk is desired, this application of heat may be con- 
tinued as long as twenty minutes, but in most cases five minutes are 



PEPTONIZED BEEF OR OYSTERS 651 

sufficient. If carried on longer than five minutes, the milk will 
become bitter and disagreeable to the taste through the development 
of peptone in excess. 

Immediately after taking the bottle from the hot water it should 
be placed on ice, in order to check further peptonizing and to keep 
the milk from spoiling; or if ice is not available the water-bath 
should be quickly brought to a boil in order to prevent further action 
of the ferment, and the bottle corked and then be put in a cool 
place. This recipe may be used where it is thought necessary to 
digest the milk before it is swallowed. Where we desire simply to 
aid digestion it is best to follow the directions already given, except 
that the bottle is not heated, but at once placed upon ice and allowed 
to remain there, being slightly warmed when it is desired to give it- 
to a child, or it may be given as a cool and refreshing drink to an adult, 
the heat of the body rapidly causing the ferment to do its work 
as soon as the food enters the stomach. When irritability of the 
stomach exists in adults, this peptonized milk may be made more 
agreeable to the taste by following the directions given in the first 
recipe, except that it must remain in the hot water for no less than 
two hours, when it is poured out into a tin cup or pan and rapidly 
brought to the boiling-point. After this it is strained through a 
piece of coarse muslin and placed upon ice. Before giving it to a 
patient this mixture may be flavored with lemon- or orange-juice 
or any form of acid that is desired, without the milk becoming 
curdled. Peptonized milk-punch is made from milk prepared in 
the way already described in the first recipe by adding St. Croix 
or Jamaica rum or brandy, and is a pleasant nutrient, particularly 
if the surface of the liquid is sprinkled with a little grated nutmeg. 

A very refreshing and agreeable drink may be made by diluting 
peptonized milk one-half with highly charged carbonic-acid water, 
and swallowing it while effervescing. 

WHOLE MILK FEEDING FOR INFANTS. 

In cases in which it is difficult or impossible to arrange for per- 
centage feeding of infants, whole milk feeding is resorted to. It 
is rarely begun before the end of the first month of life. If it is needed 
earlier, the milk is to be diluted with water one-half. At first 2 
grains of sodium citrate to each ounce of milk is used and later 1 
grain. Infants often thrive remarkably well on this plan. (See 
Sodium Citrate.) 

PEPTONIZED BEEF OR OYSTERS. 

The following method of preparing peptonized beef^ is recom- 
mended by the Fairchilds, and is very useful, as is also peptonized 
oyster stew, as first introduced by the late Dr. N. A. Randolph. 

Take J pound of finely minced raw lean beef; cold water, \ pint. 



652 FEEDING THE SICK 

Mix in a saucepan. Cook over a gentle fire, stirring constantly until 
it has boiled a few minutes. Then pour off the liquor for future use, 
beat or rub the meat to a paste, and put it into a clean fruit-jar 
with J pint of cold water and the liquor poured from the meat, and 
add 

Extracti pancreatis 20 grains (1.3) 

Sodii bicarb 15 grains (1.0) 

Shake well together, and set aside in a warm place, at about 110° 
to 115° F., for three hours, stirring or shaking occasionally; then 
boil quickly. The liquid may then be strained or clarified with white 
of egg in the usual manner, and seasoned to taste with salt and 
pepper. 

In the great majority of cases it is not necessary to strain the 
peptonized liquor, for the portion of meat remaining undissolved will 
have been so softened and acted upon by the pancreatic extract that 
it will be in very fine particles and diffused in an almost impalpable 
condition, and is therefore in a form ready for assimilation in the 
body. 

Peptonized Oysters.— Peptonized oysters are prepared by mincing 
six to twelve large oysters, and adding to them, when mixed with a 
moderate amount of their own liquid, 5 grains (0.3) of pancreatin 
or peptonizing powder and 20 grains (1.3) of sodium bicarbonate. 
The cup containing this mixture is now placed in water at 100° F., 
and allowed to remain there from ten to twenty minutes, according 
to the degree of digestion desired. After this the liquid mass is 
quickly brought to a boil to cook the oysters and stop digestion, 
and served with pepper and salt as required. Any condiment or 
flavoring substance may be used. 

PEPTONIZED ENEMATA. 

Comparatively recent investigations have proved conclusively that 
so-called nutrient enemata aid very little in maintaining nutrition, 
most of the benefit being due to the fact that the fluid part of the 
injection is absorbed but the solids remain in the bowel. 

A nutrient enema which has been much used may be prepared by 
following the directions given above for peptonizing milk, except that 
an egg, yolk and white, should be beaten up in the milk before the 
ferment is added. The effect of this enema may be increased by 
the addition of a teaspoonful to an ounce of whisky or wine. This 
should be warm when injected into the rectum. 

As the rectum is apt to become irritable if injections are given 
frequently, and particularly if the same mixture is repeated a number 
of times. This can be avoided by resorting to the "drop method" 
of Murphy and the Fowler posture. (See Peritonitis.) It is often 
well to substitute for the formula just given the following recipes: 

Von Leube recommends 5 ounces of scraped meat, chopped very 



KOUMYSS 653 

fine, and to this are added 1J ounces of finely chopped pancreas; 
the whole is suspended in 3 ounces of lukewarm water, and stirred 
to the consistence of a thick pulp. This makes one injection. Pan- 
creatin or peptonizing tablets can be as well used as the pancreas 
itself. 

Rennie's formula consists of J pound of lean meat pulled into 
shreds and added to a pint of beef-tea; to this are added 1 dram 
of fresh pepsin and J dram of dilute hydrochloric acid; the mix- 
ture is kept at a temperature of 99° F. for four hours, during which 
it is stirred constantly. If too great heat be employed, the digestive 
process will stop. 

An enema which Bidwell employs is made as follows: milk, 2 
ounces; strong beef -tea, 2 ounces; yolk of egg, 1; pancreatic solu- 
tion, 1 dram. This is to be prepared one hour before use, and to 
be kept at a temperature of 100° F.; f to 1 ounce of brandy is added, 
when necessary, immediately before use. 

Greig Smith uses 1 egg beaten up in 6 ounces of milk with 2 or 3 
teaspoonfuls of meat-jelly, or peptones may be added. This is 
administered warm with or without J ounce of brandy every five 
or six hours. 

DIGESTED GRUEL. 

Digested gruel may be made by taking thoroughly boiled hot 
gruel made from oatmeal, barley, wheat, or from arrowroot, to the 
amount of J pint (240 cc), and adding thereto, while it is hot, 
J pint (240 cc) of fresh, cold milk; to this may now be added the 
contents of one peptonizing tablet or tube, and the mixture allowed 
to stand in moderately hot water or in a warm place for twenty 
minutes before it is placed upon ice. Ten grains (0.65) of taka- 
diastase may be used in place of pancreatin. 

KOUMYSS. 

This preparation of milk which is very useful for children and 
adults during convalescence from acute or subacute exhausting 
diseases. Even children of three or four years will acquire a liking 
for it if it is not made too sour by continuing the fermentation 
process too long. The liquid is prepared as follows: Add to 1 pint 
(480 cc) of cool, perfectly fresh milk 2 teaspoonfuls (8.0) of sugar, 
and place it, after shaking thoroughly, in a clean beer or claret 
bottle. Then add J of a cake of Fleischman's compressed Vienna 
yeast, and tightly cork the bottle, standing it in a warm place or 
in a water-bath at 99° to 100° F. for eight to ten hours. Then place 
in a cool place or on ice and use as needed. It must be remembered 
that the development of carbonic gas is very great in this liquid, 
and that if an ordinary cork is inserted it must be tied in before 
the heat is applied. Further than this, the cork must be pulled very 



654 FEEDING THE SICK 

gently or the liquid will spurt all over the room. The best thing to 
use when about to open a bottle of koumyss is a "champagne tap," 
by means of which the liquid may be drawn off as needed. 

DIET LIST. 

The following bills of fare are used in the Children's Hospital 
in Philadelphia with good results, are easily prepared, and the 
directions readily carried out by the inexperienced. 

Diet in Gastro-intestinal Catarrh for a Child of Seven Years. 

Breakfast, 7.30 a.m.: Milk, with lime-water; 4 teaspoonfuls of 
lime-water to each tumblerful of milk. The lightly boiled yolks of 
two eggs, thin slices of well-toasted bread, or stale bread. 

Dinner, 12 m.: A mutton-chop without fat, broiled; or a slice of 
roast beef or mutton; occasionally a bowl of meat broth. Stale 
bread or toast. 

Supper, 7 p.m.: Milk and lime-water. Stale bread or toast, or 
milk toast. 

For drink: Filtered or boiled water. 

Starch foods to be avoided as much as possible. 

Diet for a Child Two Years Old. 

Breakfast, 7.30 a.m. Milk. The lightly boiled yolk of an egg. 
Thin bread and butter (the bread to be one day old). 

Lunch, 11 a.m.: Milk. A thin slice of bread and butter. 

Dinner, 1.30 p.m.: Beef -tea or small piece of minced roast beef 
or mutton devoid of gristle. One well-mashed potato, moistened 
with gravy. Rice and milk. 

Supper, 6 p.m.: Milk. Bread and butter. 

For drink: Boiled or filtered water. 

Diet for a Child One Year Old (Five Meals a Day). 

First meal, 7 a.m.: 2 teaspoonfuls of grated flour-ball (prepared 
as directed below) in \ pint of milk. 

Second meal, 10.30 a.m. : \ pint of milk with 4 tablespoonfuls of 
lime-water. 

Third meal, 2 p.m. : The yolk of 1 egg beaten up in 1 teacupf ul of 
milk. 

Fourth meal, 5.30 p.m.: Same as the first. 

Fifth meal, 11 p.m.: Same as the second. 

Flour-ball is to be made by taking one pound of good flour— 
unbolted if possible— tie it up very tightly in a pudding-bag; put it 
in a pot of boiling water early in the morning and let it boil until 
bedtime, then take it out and let it dry. In the morning peel off 
the surface and throw away the thin rind of dough, and with a 



BEEF-TEA 655 

grater grate down the hard, dry mass into a powder. To use this, 
take from 1 to 2 teaspoonfuls of powder, rub it down until smooth 
with a tablespoonful of cold milk, and add 1 tumblerful of hot milk, 
stirring it well all the time. 

Diet for a Child from Six to Twelve Months Old (Five Meals a Day). 

First meal, 7 a.m.: Mellin's food, 1 tablespoonful or flour-ball 
(grated) , 1 or 2 teaspoonfuls (prepared as directed above) ; hot water, 
4 tablespoonfuls; warm milk, enough to make f pint. Dissolve the 
Mellin's food or rub down the grated flour-ball in the hot water by 
stirring, then add the milk; mix thoroughly. 

Second meal, 10.30 a.m., and third meal, 2 p.m. : A breakf astcupful 
of milk with 4 tablespoonfuls of lime-water. 

Fourth meal, 5.30 p.m.: Same as first. 

Fifth meal, 10.30 p.m.: Same as second. 

SOYA BEAN FLOUR FOR INFANT FEEDING. 

Ruhrah has highly recommended the use of soya bean flour for 
children for whom fresh milk cannot be obtained, or when it is of 
questionable quality; or, again, When cow's milk, even when properly 
diluted, disagrees with the patient, as shown by vomiting or diarrhea. 
This flour is always used in conjunction with barley flour as follows: 

One level tablespoonful of soya flour, 2 level tablespoonfuls of 
barley flour, a pinch of salt, and 1 quart of water are mixed and 
boiled for at least twenty minutes. ' Afterward fluid lost in boiling 
is replaced by pure water. To this mixture is added condensed milk 
in proportions varying from 1 to 16 to 1 to 8, according to the age 
of the child and the digestive state. From 2 to 8 ounces are used 
at a feeding every three hours. In older children the amount of 
soya flour and barley flour may be doubled, but if too much soya flour 
is used the stools become foul, watery, and dark colored. This is 
also prone to occur if barley flour is not employed, even if the amount 
of soya flour be^proper. 

BEEF-TEA. 

Take 1 pound of lean beef and mince it. Put it with its juice into 
an earthen vessel containing a pint of tepid water, and let the whole 
stand for one hour; strain well, squeezing all the juice from the 
meat. Place on a fire, and slowly raise just to the boiling-point, 
stirring briskly all the time. Season with salt and pepper to taste. 
In administering this always be careful to stir up the sediment. 

Or, take 2 pounds of beef without fat or bone, and half a break- 
f astcupful of cold water; place in a jar in a saucepan of water; 
simmer four hours. 



656 FEEDIXG THE SICK 



RESTORATIVE BEEF-ESSENCE (RINGER). 

Take 1 pound of fresh beef free from fat, chop it fine, and pour 
over it 8 ounces of soft water, add 5 or 6 drops of hydrochloric acid 
and 50 or 60 grains of common salt; stir it well, and leave for three 
hours in a cool place. Then pass the fluid through a hair sieve, 
pressing the meat slightly, and adding gradually toward the end 
of the straining about 2 ounces more of water. The liquid thus 
obtained is of a red color, and possesses the taste of soup. It should 
be taken cold, a teacupful at a time. If preferred warm, it must not 
be put on the fire, but heated in a covered vessel placed in hot water. 

Should it be undesirable for the patient to take the acid, this 
soup may be made by merely soaking the minced beef in distilled 
water. Or, take 1 pound of beef free from fat and skin, chop it very 
fine, add a little salt, and put it into an earthen jar with a lid, such 
as is used for roasting venison; seal the edges with a thick paste, and 
place the jar in an oven for three or four hours; strain through a 
coarse sieve. Give the patient two or three teaspoonfuls at a time. 
Or, cut in small pieces 1 pound of lean beef from the sirloin or rump, 
and place it in a covered saucepan, with \ pint of cold water, by the 
side of a fire for four or five hours; then allow it to simmer gently 
for two hours, skim well, and serve. 



BARLEY-WATER. 

To prepare barley-water, put 2 good-sized teaspoonfuls of washed 
pearl barley with 1 pint of cold water in a saucepan, and boil slowly 
down to two-thirds. Strain. 

Barley-water for Adults. 

Take of finest barley \ pound; to this add 1 quart of water and 
boil to 1 pint; strain and add 1 quart of boiled milk. To this add 
6 ounces each of brandy and lime-water; sweeten to taste; flavor 
with nutmeg and rind of lemon rubbed with sugar. This forms a 
most nourishing and palatable drink when kept cold on ice. 



OATMEAL -WATER. 

Add 1 tablespoonful of oatmeal-flour to 1 pint of water and boil 
down to two-thirds of a pint. Strain. To this may be added, as 
additional nourishment, beaten white of egg. 



RICE-WATER. 

Rice-water is made by boiling 2 ounces of clean rice in 2 quarts 
of water for an hour and a half. 



BRAX BREAD FOR DIABETICS 657 



WINE -WHEY. 

Boil 1 pint of fresh milk; while boiling pour in 1 small tumblerful 
of sherry wine (8 tablespoonfuls) ; bring to the boil a second time, 
being careful not to stir it; as soon as it boils set it aside until the 
curd settles, and pour off the clear whey. 

ALMOND BREAD FOR DIABETICS. 

Take of blanched sweet almonds \ pound; beat them as fine as 
possible in a stone mortar; remove the sugar contained in this meal 
by putting it into a linen bag and steeping it for a quarter of an hour 
in boiling water acidulated with vinegar; mix this paste thoroughly 
with 3 ounces of butter and 2 eggs. Next add the yolks of 3 eggs 
and a little salt, and stir well for some time. Whip up the whites 
of 3 eggs and stir in. Put the dough thus obtained into greased 
moulds, and dry by a slow fire. 

BRAN BREAD FOR DIABETICS. 

Take a sufficient quantity (say 1 quart) of wheat-bran; boil it in 
two successive waters for a quarter of an hour, each time straining 
it through a sieve; then wash it well with cold water (on the sieve) 
until the water runs off perfectly clear; squeeze the bran in a cloth 
as dry as possible, then spread it thinly on a dish and place it in a 
slow oven; if put in at night, let it remain until morning, when, if 
perfectly dry and crisp, it will be fit for grinding. The bran thus 
prepared must be ground in a fine mill and sifted through a wire 
sieve of such fineness as to require the use of a brush to pass it 
through; that which remains in the sieve must be ground again 
until it becomes quite soft and fine. Take of this bran powder 3 
ounces (some patients use 4 ounces), the other ingredients as follows: 
3 new-laid eggs, 1| ounces (or 2 ounces if desired) of butter, and 
about \ pint of milk; mix the eggs with a little of the milk, and 
warm the butter with the other portion; then stir the whole well 
together, adding a little nutmeg or ginger or any other agreeable 
spice. Bake in small tins (patty-pans), which must be well buttered, 
in a rather quick oven for about half an hour. The cakes, when 
baked, should be a little thicker than ship biscuit; they may be 
eaten with meat or cheese at breakfast, dinner, and supper; at tea 
they require rather a free allowance of butter, or they may be eaten 
with curd or any of the soft cheeses. 

It is important that the above directions as to washing and 
drying the bran should be exactly followed, in order that it may 
be freed from starch and rendered more friable. The bran in its 
common state is soft, and not easily reduced to fine powder. In 
some seasons of the year, or if the cake has not been well prepared, 
42 



658 FEEDING THE SICK 

it changes more rapidly than is convenient, owing to moisture. 
This may be prevented by placing the cake before a fire for five or 
ten minutes every day. 

ALMOND MILK. 

Add 1 to 2 ounces of scalded sweet almonds, deprived of their 
skins, to a little hot water and thoroughly rub them into a pulp, 
adding nearly a pint of scalding water while rubbing. Then boil 
for fifteen minutes; strain, and add enough water to make a pint. 
This may be sweetened with sugar if desired, and is excellent for 
children who cannot take milk. 

ARTIFICIAL MILK FOR DIABETICS. 

Williamson has given the following recipe: "To about a pint 
of water placed in a large drinking-pot or tall vessel, about two 
or three tablespoonfuls of fresh cream are added and well mixed. 
The mixture is allowed to stand for twelve to twenty-four hours, 
when most of the fatty matter of the cream floats to the top; it can 
be skimmed off with a teaspoon easily, and on examination it will 
be found practically free from sugar. The milk-sugar remains 
dissolved in the water. This fatty matter thus separated is placed 
in a glass and mixed with water. Then the white of an egg is added 
and the mixture well stirred. The water and white of the egg 
are added in sufficient quantities to make a mixture which has 
the exact color and consistence of ordinary milk. If a little salt 
and a trace of saccharin be added, a palatable drink is obtained 
which has almost the same taste as milk, and which contains a 
large amount of fatty material and is practically free from milk- 
sugar. With very little practice the right proportions can be easily 
gUessed, and, of course, much larger quantities than those men- 
tioned can be prepared." 

JUNKET. 

Add from \ to 1 teaspoonful of Parke, Davis & Co.'s essence of 
pepsin or Fairchild's essence of pepsin to a pint of milk, which 
should be at body-heat. Place the milk in a cool place, and after 
the curd has formed serve cold and flavor with powdered nutmeg 
or vanilla. If there be too great feebleness of digestion to digest 
the curd, the liquid whey may be given, as it contains the salts 
and soluble albuminoids of the milk. 

Junket may be considerably increased in nutritive value if to the 
milk before it is warmed is added an egg which has been thoroughly 
beaten. In place of the egg a tablespoonful of cocoa may be added 
to 2 teaspoonfuls of sugar and rubbed into a paste with a little water. 
This is added to the warm milk, and then the pepsin is added to 
make the junket. 



MALT SOUP 659 



MULLED WINE. 

Boil some spices— cloves, nutmeg, cinnamon, or mace— in a little 
water, and add as much of this decoction as is necessary to flavor a 
wineglassful of sherry or any other wine. Add sugar to taste, and 
bring the mixture to the boiling-point. If claret is used, it will 
require more sugar than if a less sour wine is employed. The vessel 
for heating the wine should be scrupulously clean. 

WATERED TOAST. 

Brown several pieces of bread, and carefully butter the toast so 
that the butter is equally distributed. Place enough salt over 
the toast to flavor it and add pepper to taste. Finally pour as 
much boiling water on the edges of the crust as is necessary to soak 
them thoroughly, and serve. This is a more agreeable dish than 
would be imagined, and is useful where milk toast is distasteful. 

MILK, FLOUR AND MALT. 

For an infant suffering from hard stools with putrefactive odor and 
an ammoniacal urine. 

Rub up four teaspoonfuls of baked flour with a little milk to form 
a paste. Add more milk with constant stirring up to 12 ounces and 
strain through a sterile sieve. In another container put two teaspoon- 
fuls of extract of malt and dissolve in 24 ounces of warm water, add- 
ing 20 grams of bicarbonate of sodium. Mix the two fluids and, with 
constant stirring, heat slowly until the mixture has boiled for two 
minutes. 

MALT SOUP. 

Malt soup is a useful food in infants who are suffering from entero- 
colitis or general emaciation and in those with imperfect digestion 
of the fats. This is easily prepared by using Mead's Dry Malt 
Soup which contains maltose and dextrin, 47 per cent.; wheat flour, 
47 per cent.; potassium carbonate, 1 per cent., and moisture 5 per 
cent. For babies under three months of age the following formula 
may be used. 

Whole milk 7 to 10 ounces 

Boiled water 14 to 20 ounces 

Dry malt soup stock 2 rounded table- 
spoonfuls. 

For children over three months: 

Whole milk 12 to 24 ounces 

Boiled water 12 to 24 ounces 

Dry malt soup stock 2 to 4 rounded 

tablespoonfuls. 



660 FEEDING THE SICK 

In either case mix enough of the milk and water with the dry 
soup stock to make a thin paste. Add the balance and boil for 
fifteen minutes with careful stirring. Do not use a double boiler. 
For children under three months feed 2 to 3 ounces every two hours. 
For children over three months feed 4 to 8 ounces according to age 
and weight every three or four hours. 

In considering this subject scientifically there are several facts 
to be understood. Starch and dextrin, the first step in starch 
digestion, are polysaccharides and as such are not utilizable until by 
the action of enzymes they are converted first into a disaccharide 
such as maltose and then one step further by enzymes in the diges- 
tibe tube, or in the blood, into a monosaccharide glucose. When 
cane-sugar, a disaccharide, is taken it is inverted into two mono- 
saccharides, glucose and fructose, and if milk-sugar or lactose*, also 
a dissaccharide, is ingested it must be split by acids or enzymes into 
the monosaccharides glucose and galactose. Therefore the use of 
maltose, cane-sugar or milk-sugar is equivalent to employing starch 
already partly changed to a form in which it can be used by the 
body, but it has been proved that the body of a child finds it 
twice as easy to take up maltose as to assimilate either lactose 
or cane-sugar, although all these are disaccharides. The very 
readiness with which maltose is taken up is on the one hand advan- 
tageous and on the other disadvantageous. Little difficulty is 
experienced in its assimilation, but the very readiness of its absorp- 
tion tends to flood the body with it before it can be changed into 
glucose and utilized or stored. Commercial maltose containing 
dextrin is therefore not to be condemned because of the presence 
of the dextrin for it retards maltose absorption to some extent 
and, as it has to be changed into a monosaccharide, it is taken up 
slowly and acts as an adjuvant to maltose. It is as if a predigested 
food were taken before bread, thereby giving immediate energy, to 
be followed by a gradual supply from the slowly converted bread 
to maintain energy. The readily obtained energy from the maltose 
also provides energy to aid the body in converting the dextrin into 
maltose. Finally the starch present is changed to maltose so that 
the stomach receives one feeding but the tissues three feedings as 
conversion and assimilation go on. 

Resort may also be had to the so-called corn-syrup commonly sold, 
as it contains about 55 per cent, of dextrin, 30 per cent, of maltose 
and 15 per cent, of glucose. As it is too thick to mix readily with 
milk it may be diluted half with water, 3 per cent, of corn-syrup or 
6 per cent, of the diluted syrup being added to the milk and gradu- 
ally increased if nutrition is impaired and no diarrhea ensues. 

Malt soup may be also made from the Extract of Malt official 
in the U. S. P., or by using the Malt Soup Extract made by the 
Maltine Company. The ingredients in the preparation are varied 



MALT SOUP 



661 



to the needs of the individual, but a standard formula may be 
prepared as follows: 

Mixture No. 1. 

Malt soup extract 2\ fluidounces 

Sterile warm water 22 fluidounces 

Thoroughly dissolve. 

Mixture No. 2. 

Wheat flour 2\ ounces 

Fresh milk 11 fluidounces 

Mix thoroughly and strain through a fine sieve. 



These mixtures are now mixed together thoroughly and are boiled 
for three minutes with constant stirring. After rapid cooling pour 
into sterile feeding bottles and store in a cool place, the bottles 
being plugged with sterile cotton. 

This mixture has a value of about 696 calories and as it is gener- 
ally recognized that an infant requires approximately 45 calories 
to the pound in twenty-four hours the quantity of this malt soup 
and its dilution required by the child may be estimated with fair 
fair accuracy. 



PART IV. 

DISEASES. 



ABORTION. 



The treatment of abortion divides itself into three parts: the 
first for its prevention, the second for its arrest when threatened, 
the third for its proper care when inevitable. 

In the preventive means we find, as in nearly every branch of 
medicine, that the use of hygienic measures is more important than 
the employment of drugs. If previous abortions are known to be 
due to syphilis, high blood-pressure, endometritis, or uterine dis- 
placements, these conditions must be relieved by the proper remedies. 
If there exists no apparent cause for the interruption of normal 
gestation, the patient should use a simple diet, lead a quiet life, 
avoid sexual intercourse, sleep on a hard bed, and resort only to 
gentle exercise. Fresh air is, however, a necessity, and should be 
plentifully supplied. The food should be light, but nutritious and 
palatable, and a sufficient variety supplied to avoid any repugnance 
to a given dish. In many cases abortion is due to deficient nutri- 
tion of the fetus, either by reason of faulty assimilation on the part 
of the mother or because of poor food, so that if anemia, debility, 
or other impoverished states of the maternal system be present, 
these should be treated at once. The clothing should be loose, the 
night's sleep undisturbed and of full length, and the mind be set 
at rest as far as possible in respect to household and other worries, 
and particularly diverted from the thought of possible uterine 
disturbance. 

The use of drugs is to be limited strictly to the fulfilment of a 
distinct indication, and the employment of cathartics is to be avoided, 
the bowels being kept in order by fresh fruits in moderate quantity 
or by mild laxatives, such as cascara sagrada in small doses and 
phenolphthalein. If these fail, rhubarb may be resorted to and 
castor oil in capsule may be used. Podophyllin, senna in full doses, 
saline purges in active amounts, and aloes are not to be used if 
they can be avoided. If the woman be exceedingly stout and ple- 
thoric, saline purges are indicated to act as depletants. It is hardly 
necessary to add that elaterium and scammony or jalap are not safe, 

(663) 



664 DISEASES 

and can only be used if dropsy and ascites are present, and when we 
must choose the least of two evils. Strychnine, which stimulates the 
spinal cord, should never be employed, and cantharides, oil of erig- 
eron, and manganese ought not to be used unless they are for some 
reason very necessary. Although quinine is not of itself an aborti- 
facient, it is unsafe in very large doses if an abortive tendency is 
present, and can only be used as a prophylactic in cases in which 
abortion is brought about by malarial infection. 

The only drug which seems to be of any service as a prophylactic 
to be taken all through pregnancy is the fluidextract of viburnum 
prunifolium, the dose of which is ^ to 1 dram (20.0-4.0). This drug- 
is said to be a uterine sedative and to have no injurious effect upon 
the mother or child. 

The arrest of threatened abortion is one of the most difficult 
duties which come to the physician, and there is no doubt that 
large doses of morphine or opium are the best means of quieting 
the uterus. While viburnum prunifolium may be resorted to, we 
do not know enough of it to rest assured of its value, but it should 
be tried if opium is not at hand or fails. The patient should be at 
once placed in bed in the most comfortable position, be so covered 
as to prevent overheating or taking cold, and receive by the hypo- 
dermic needle f grain (0.015) of morphine, or, better still, a rectal 
injection of warm starch- water containing 45 minims (3.0) of lauda- 
num. The bulk of the injection should be small in order not to 
disturb the bowels, and must be at the body temperature. If this 
is not done, a suppository of the aqueous extract of opium, containing 
} to J grain (0.015-0.03), should be used. Ice-cold drinks should 
be given, and no tea or coffee allowed. This treatment quiets the 
uterus, allays nervousness and restlessness, and at least puts off 
the abortion for a few hours. Venesection has been practised in 
very plethoric women with advantage. 

When an abortion is inevitable, it is to be treated by measures 
directed to the avoidance of hemorrhage, the thorough delivery of 
the ovum and its appendages, and the prevention of inflammation 
and septicemia. The latter accident is to be prevented by the most 
rigid asepsis of the patient and physician. For the prevention of 
hemorrhage a number of balls of aseptic absorbent cotton tightly 
wound with thread to the size of a small egg should be packed into 
the vagina back of and around the cervix until the bleeding is con- 
trolled, and, while a small amount of iodoform may be dusted over 
them before they are inserted, no astringents are to be applied, 
unless it be tannic acid to coagulate the blood in the cotton, as 
astringents cannot reach the bleeding spot. Sponges ought never 
to be used, as they often fail to control the bleeding and rapidly 
become septic. By means of this packing the blood in the uterus 
cannot escape, and as the uterine walls contract they urge the liquid 
between the membranes, thereby causing complete separation. 



ABSCESS 665 

After the tampons are applied ergot should be used in the dose of 
a dram of the fluidextract or a tablespoonful or two of the wine, 
unless the uterine contractions are already active. Generally after 
twenty-four hours the removal of the tampons will show the ovum 
to be in the vagina, but if part of it remains in the uterus, the follow- 
ing measures should be resorted to: The administration of ergot 
should be stopped unless the hemorrhage is severe, and the uterine 
cavity is to be cleared by the use of the fingers of the attendant, 
who grasps the membranes and draws them away. In skilful hands 
the curette may be employed. If the cervical canal is too small, it 
must be dilated by dilators. After the membranes are removed the 
tincture of iodine may be applied to the inner surface of the uterus 
as a hemostatic, antiseptic, and alterative; or the uterus may be 
douched with a 2 per cent, solution of creolin in warm water, about 
a quart being used at a low hydrostatic pressure. A pumping syringe 
should not be used. 

Manual and instrumental interference is less frequently resorted to 
than it used to be as solutions of continuity are produced thereby, 
whereby local or general infection may occur. 

The after-treatment consists in the use of small doses of ergot and 
quinine, of vaginal antiseptic irrigation, or even of uterine irrigation, 
if it is needed, and the maintenance of perfect rest for one or two 
weeks, or longer if possible. Ergot ought not to be given if there 
is reason to believe that portions of the membranes or blood-clots 
are in the uterus, as by contraction of the os uteri it may imprison 
materials which then become septic. (See Puerperal Diseases.) If 
fever arise the patient should be put in a posture favorable to uterine 
drainage, as Fowler's position, and the Murphy drip used. 

ABSCESS. 

The medical treatment of abscess is to support the body if the 
suppuration be prolonged or in large amount or if debility exists. 

As acute abscess in its early stages is simply a localized inflam- 
mation with hyperemia and an outpouring of leukocytes, it may 
often be modified by a poultice, made by moistening breadcrumbs 
with lead-water, or lead-water may be placed on lint and applied 
in this way. Belladonna ointment smeared over the same area 
may be of service. If a gland be involved, the needle of a hypo- 
dermic syringe may be inserted perpendicularly into its center and 
5 to 10 minims (0.3-0.6) of a 2 per cent, solution of phenol injected 
into the swelling. This method has been found of singular efficacy 
in bubo when pus seems just about to form. It is very often cura- 
tive, but should not be used in a stronger or weaker solution than 
that named. Another useful abortive method for the treatment of 
the early stages of abscess is the application, externally, of a strong 
solution of nitrate of silver, 20 to 40 grains to 1 ounce (1.3-2.6:30.0) 



666 DISEASES 

of water, by means of a camel' s-hair brush, all over the skin covering 
the area involved, or by the use of the tincture of iodine in a similar 
manner. 

If it becomes evident that pus is going to form, then resort must 
be had to poultices, which by their heat and moisture will aid in 
the formation of pus by favoring the escape of leukocytes and by 
softening the tissues. The best form of poultice for this purpose is 
to use lint which has been saturated with a 1:4000 solution of mer- 
curic chloride, the moisture being retained by a piece of rubber 
dam placed over the lint. If pus forms and fluctuation ensues, the 
abscess should be freely opened, drained, washed out by normal 
salt solution, or bichloride solution 1:5000, and dressed with anti- 
septic gauze. If it is tubercular, the abscess may be opened in the 
ordinary manner, and the cavity packed with iodoform gauze, or 
if it cannot be drained in this way it should be drained by aspiration, 
and an ethereal solution of iodoform injected and allowed to remain 
in the abscess-cavity if it is a small one. The opening is now closed 
by a pledget of cotton wet with tincture of benzoin, and an antiseptic 
dressing applied over it. Not more than 20 grains (1.3) of iodoform 
should be so used in the treatment of tubercular abscess, as larger 
amounts have caused poisoning. (See also Bismuth, Part II.) 

A very good treatment for slow abscess is to wash out the cavity 
with a 10-volume solution of peroxide of hydrogen, provided there 
is a free exit for the gas which is given off. 

If the abscess is chronic (cold abscess) and associated with great 
weakness, resort must be had to the internal use of iron in the form 
of the tincture of the chloride, cod-liver oil, quinine as a tonic to 
prevent hectic fever, and the use of nutritious, easily digested food. 
Alcohol may be used, and should be given with milk or in egg-nog. 
(See Vaccine-Therapy.) 

The following tonic pill or solution is of service: 

1$ — Strychninse sulphatis gr. j (0.06) 

Arseni tfioxidi gr. J (0.015) 

Ferri reducti gr. x (0.65) 

Quininae sulphatis . gr. xx (1.3). — M. 

Fiant pilulae, No. xx. 

S. — One t. i. d. after meals. 

Or 

1$ — Tincturae cinchonse compositae, 

Tincturae gentianse compositae, 

Tincturse cardamomi compositae . . . . aa f Siij (90.0). — M. 
S. — Dessertspoonful (8.0) t. i. d. after meals. 

Having described the means of treatment, it is to be explained 
how these measures act. The lead- water acts locally as an astrin- 
gent and sedative, while the belladonna by its action on the blood- 
vessels contracts the dilated capillaries and allays pain. When 
phenol is injected into an enlarged gland, it acts as an anesthetic, 
as an antiseptic, and as an astringent. The nitrate of silver appli- 



ACNE 667 

cations act by constringing the bloodvessels, as local sedatives, and 
as counterirritants. The iodine applications do likewise, and also 
exercise an antiseptic influence. The object in using the anti- 
septic irrigations is self-evident, and the employment of iodoform 
in tubercular abscess rests upon the studies of Bruns, of Tubingen, 
and many others, who have found by experiment that the use of 
iodoform is fatal to the Bacillus tuberculosis. As large numbers 
of corpuscles are destroyed in the formation of pus, and other sources 
of vitality are sapped by its formation, the use of arsenic and iron 
to replace the loss is necessary, and of cod-liver oil and tonics to 
increase the blood-corpuscles and the ability to assimilate food. 
(For the use of bismuth in the treatment of abscess see Bismuth, 
Part II.) 

ACNE. 

This affection occurs in so many forms and arises from such 
different causes that a thorough consideration of its treatment can- 
not be here given: suffice it to state that arsenic is a remedy which 
will often aid in the cure and prevent a relapse if used in small doses 
for a long period; that is, 1 to 3 minims (0.06-0.2) of Fowler's solu- 
tion three times a day for a month or two. This is particularly 
useful if debility and anemia underlie the disease. If the anemia 
be marked, the proper treatment is that directed to the cure of 
this condition (see Anemia); if obstinate constipation is present, 
relief must be obtained by saline purges and the bowels kept in 
order by cascara sagrada or some similar drug. If general debility 
exists, cod-liver oil is of great service; or if much pustulation is 
present, calx sulphurata, in the dose of ^ to J grain (0.006-0.008), 
may be used in pill form three times a day. In menstrual acne, 
sulphur may be used internally, in the form of the confection of 
sulphur of the British Pharmacopoeia, to open the bowels, and 
applied as a wash to the face in the following form: 

3— Sulphuris 5J (4.0) 

Glycerini f 5 j (30.0) 

Aquse rosse q. s. ad f5viij (240.0). — M. 

S — Apply twice or thrice a day. 

Or the following may be used in cases of severe inflamed acne: 

1$ — Sulphuris iodidi gr. xxx (2.0) 

Cerati . 5j (30.0).— M. 

S. — Apply to the parts night and morning. 

If the skin is very atonic, muddy, and torpid, it should be bathed 
night and morning with hot water and castile soap, or even with 
the tincture of green soap, and well rubbed with a rough towel. 
After this the following salve may be thoroughly applied: 

1$ — Sulphuris prsecipitati 5ss (2.0) 

Adipis lanse hydrosi, 

Adipis aa 5ss (16.0).— M. 

S. — Apply as directed. 



668 DISEASES 

If the green soap causes irritation, some bland application should 
follow it, such as simple cerate or the emulsion of the oil of sweet 
almonds. If the pustules be large, they may be incised, a small 
Bier cup applied, and vent given to their contents, the sac being 
swabbed with a drop of phenol, or a drop of camphor, 3 parts, phenol, 
1 part, may be employed. (See Phenol.) If induration is great, 
ichthyol ointment of the strength of 20 parts of ichthyol to 100 of 
lard should be well rubbed in, or resorcinol, 10 to 20 grains to the 
ounce of lard (0.6-1.3:30.0), be applied. Mercurial ointment may 
also be used to lessen induration, but several days should elapse 
between its use and that of sulphur, as otherwise a black sulphuret 
of mercury will be formed and stain the skin. 

The diet should be carefully regulated and fatty foods avoided. 

Stains of the skin after an acne pustule has healed may be removed 
by- 

I£ — Aquae hydrogenii dioxidi f3j (4.0) 

Adipis lanae hydrosi ... f3vj(24.0). — M. 

Ft. unguent. 

S. — Apply locally. 

An autogenous vaccine is often very valuable. Indeed, staphylo- 
coccus vaccine has done better in acne and furunculosis than in 
any other use of vaccine-therapy. (See Vaccine-therapy.) 

ADENITIS. 

Cervical adenitis is an inflammation of the lymph nodes, usually 
due to tuberculosis. It may also arise from other forms of infection 
by way of the mouth or tonsils. 

If the condition is a simple enlargement, it may be treated by 
applying iodine ointment and lard, half-and-half, night and morning, 
care being taken that the use of the ointment is stopped as soon as 
reddening of the skin appears or if fluctuation develops. If for any 
reason the ointment cannot be used, the tincture of iodine may be 
thoroughly painted over the swelling, but this treatment is less 
efficacious. The following is a useful application: 

3— Ichthyolis f 3iv (16.0) 

Adipis benzoinati f5ij (60.0).— M. 

S. — Rub gently a small piece of the ointment over the swelling t. i. d. 

Syrup of the iodide of iron, in the dose of 5 to 20 drops (0.3-1.3), 
may be given, and tonics should be used to improve the systemic 
condition. A fresh-air life and residence at the seaside is desirable. 
As soon as fluctuation or reddening shows the formation of pus, all 
abortive treatment should be stopped, and a poultice be applied for 
twenty-four to forty-eight hours until the swelling is ready for 
lancing. Lancing is better than allowing the abscess to break, as 
the scar left in after years is a mere line instead of a large cicatrix. 



AMBLYOPIA AND AMAUROSIS 669 

If, after fluctuation threatens, the swelling disappears in part 
under rubbing with an ointment, this indicates not betterment, but 
that the abscess has ruptured into the surrounding tissues and it 
should be incised at once, freely drained, and swabbed out with 
tincture of iodine. The radical operation of removal of the enlarged 
glands should, if possible, wait until the process is localized. Excel- 
lent judgment as to the time of operation is often required to prevent 
general infection as the result of operation. 

When these nodes are chronically enlarged they are best treated 
by radium or the .r-rays particularly if they are tuberculous. If due 
to malignancy equally good results are more difficult to obtain but 
these methods should be resorted to before the knife is decided upon 
as the best measure for relief. When hard fibrous masses are present 
as the result of prolonged acute or subacute inflammation, and are 
disfiguring operation is indicated. 

ALCOHOLISM. 

(See Alcohol.) 

ALOPECIA. 

This affection, when due to a parasite, is best treated, according 
to Crocker, by first pulling out all the loose hairs around the bald 
spot and then painting the affected surface with linimentum can- 
tharidis (liquor epispasticus) . Three coats of this liquid should be 
employed, and each coat allowed to dry before the next is applied. 
In other cases an ointment of chrysarobin, ^ to 1 dram (2.0-4.0) to 
the ounce (30.0) of lanolin, may be used, but care must be exercised 
that too much staining of the skin and clothes does not result. 
Another equally good application is 2 grains (0.12) of mercury 
bichloride to 1 dram (4.0) of rectified spirit and 7 drams (28.0) of 
oil of turpentine. This mixture may be rubbed in with the finger 
over and around the patch. If the patient's skin will stand it, 5 
grains (0.3) of the corrosive sublimate may be used in place of 2 
grains (0.12). 

AMBLYOPIA AND AMAUROSIS. 

Amblyopia (or dulled vision) and amaurosis (or blindness) usually 
refer to defective sight or its total loss, the result of functional dis- 
turbance of the retina, optic nerve, or visual centers, and unaccom- 
panied by changes in the eye-grounds in the beginning of the disease. 
These terms, however, also include cases of partial or complete blind- 
ness in which optic-nerve atrophy subsequently develops, and are 
often used to describe ocular disorders not limited by the definitions 
here employed. These cases may be gathered into certain groups: 

I. Congenital amblyopias and amblyopias from non-use of the 
eye. In these there is often a high degree of error of refraction, 



670 DISEASES 

usually far-sightedness; the latter is seen when an eye is debarred 
from binocular vision by a squint. In both the treatment consists 
in as perfect a correction of the optical error as possible, and, in case 
one eye alone is involved, the separate exercise of its functions. 
Congenital amblyopias may include incurable defects in the structure 
of an eye. 

II. Amblyopias the result of (a) general diseases or conditions— 
typhoid fever, the exanthemata, syphilis, scurvy, malaria, influenza, 
etc.; (b) local diseases or conditions— hemorrhoids, hemorrhage, preg- 
nancy, disordered menstruation, kidney disease, diabetes, migraine, 
disorders of the nervous system, functional nervous disease, etc. 

The remedies indicated by the special cause are to be employed, 
the medicinal agents most usually needed being mercury, iodide of 
potassium, pilocarpine, particularly in uremic amaurosis, emmena- 
gogues, and tonics, especially hypodermics of strychnine. As local 
measures repeated fly-blisters to the temples, wet and dry cups, and 
the constant electric current are used. The nape of the neck may 
be cauterized. In hysterical cases metallo-therapy may be tried. 

III. Amblyopias the result of the action of certain medicinal and 
toxic agents. 

The abuse of alcohol, and particularly of tobacco, produces a 
form of amblyopia characterized by the development of a scotoma 
or an area in the center of the field of vision in which the appre- 
ciation of red and green is lost or greatly diminished. Quinine in 
excess has, in a number of instances, been followed by temporary 
blindness, which is usually denominated quinine amaurosis. The 
blindness following the administration of toxic doses of ethyl hydro- 
cuprein (optochin), especially in the treatment of pneumonia, 
resembles that of quinine amblyopia. Methyl alcohol by itself or 
in so-called purified wood alcohol which appears in commerce under 
the name of Columbian Spirits, Colonial Spirits, Eagle Spirits, 
Manhattan Spirits, etc.; or in the form of adulterated essence of 
ginger or bay rum, even in comparatively small quantities, may 
produce rapid blindness and atrophy of the optic nerve. Of less 
frequent occurrence are the cases of amblyopia produced by the 
toxic action of salicylic acid, lead, silver, mercury, osmic acid, nitro- 
benzol filix mas, thyroid extract, the vapor of disulphide of carbon 
and carbon monoxide. Blindness from atrophy of the optic nerves 
has not infrequently followed the administration of atoxyl and of 
the other arsenates, for example, soamin, arsacetin, hectin, osrudin. 
The harmful action is probably due to the aniline in these compounds. 
In all instances the patient must be withdrawn from the influence 
of the poison ; in tobacco amblyopia, in its early stages, this is usually 
sufficient to effect a cure. The remedies which have proved of the 
greatest utility are digitalis, inhalations of nitrite of amyl, nitro- 
glycerin, and strychnine. Diaphoresis is valuable. Iodide of potas- 



AMBLYOPIA AND AMAUROSIS 671 

sium should be exhibited in chronic cases, and always in amblyopias 
the result of lead poisoning. The constant current has also been 
employed. 

IV. Amblyopias the result of direct or indirect injury or from 
reflex irritations. 

Traumatic amblyopias may follow a blow upon the eye itself 
or an injury of the skull or spinal cord. To carious teeth, intestinal 
irritations, and the presence of parasites a certain number of ambly- 
opias have been attributed, but while it is not possible to disprove 
the association, such cases must be received with doubt. After 
the removal of the cause strychnine should be exhibited. Modern 
methods of examination have greatly lessened the number of condi- 
tions to which the older writers applied the words "amblyopia" and 
"amaurosis;" indeed, it is time to dismiss these words from classi- 
fications of ocular disorders, except in so far as they are synonyms of 
dimness of vision or of loss of vision. 

Optic Neuritis and Optic-nerve Atrophy. 

Optic neuritis (papillitis and choked disc (papilledema) most 
frequently depend upon diseases of the brain (tumor, abscess) or 
inflammation of its membrane (meningitis). They are also symp- 
toms of numerous disorders— suppression of the menses, exposure 
to cold, rheumatism, anemia, syphilis, uremia, lead-poisoning, etc. 
The remedies are those naturally suggested by the disease or con- 
ditions which has called it into existence. The prognosis depends 
upon the cause. Mercury, iodide and bromide of potassium, the 
salicylates, pilocarpine, local blood-letting, and fly-blisters are com- 
monly employed. Choked disk dependent upon increased intra- 
cranial pressure, in its turn due to brain tumor, is best treated by 
decompressive trephining, and if the tumor is accessible by removal 
of the growth. 

Optic-nerve atrophy may be primary, secondary, consecutive (neu- 
ritic or post-papillitic) or may be due to retinal or choroidal disease, 
or due to various causes already named in connection with the 
description of the effect of toxic agents and traumatisms. Common 
causes of primary atrophy are syphilis, locomotor ataxia, paretic 
dementia and insular sclerosis. 

Treatment.— This depends upon the cause. If syphilis is present, 
the usual remedies are indicated; but mercury is useless in advanced 
cases, even in syphilitics. While salvarsau or neosalvarsan or 
their equivalents, arsphenamme and neoarsphenamine, exercise no 
detrimental effect on a healthy optic nerve, at one time it was main- 
tained that they exerted an evil influence on tabetic atrophy. Recently 
this contention has been largely set aside and there are now a num- 
ber of observations on record which tend to show that neoarsphen- 
amine, if used early and while color percepti6n is still good, represents 



672 DISEASES 

a therapeutic agent of value in the treatment of tabetic atrophy. 
Arsphenaminized serum, injected intraspinously (Swift-Ellis method), 
may do good if employed before the degenerative process has begun. 
Strychnine has been much employed, administered in full doses, 
preferably by the hypodermic method; it may be enforced by nitro- 
glycerine or inhalation of amyl nitrite. Other remedies, according 
to the cause, are iodide of potassium, nitrate of silver, phosphorus, 
arsenic, iron, santonin, lactate of zinc, hypodermics of antipyrin 
(Valude), and injections of organic liquids, all of doubtful value. 
Negative galvanism has been advised, and good results have been 
reported. Coleman especially recommends the sinusoidal current, a 
binocular electrode being placed over the eyes and an oval pad to 
the nape of the neck. The treatment should take place for twenty 
minutes each day. High-frequency currents have been advocated 
and they should be tried. There is no satisfactory evidence that 
radium and the Roentgen rays are useful therapeutic agents in the 
treatment of optic-nerve atrophy. 

AMENORRHEA. 

This condition depends upon so many causes for its existence 
that it must be treated in many different ways. If ordinary anemia 
or chlorosis shows that there is a deficient supply of blood, measures 
adapted to the relief of such a state are required. (See Anemia.) 
In amenorrhea due to constipation saline purges or other laxatives 
may be used, and the best of these purges is aloes. As constipation 
and anemia are often present simultaneously, a combination of 
aloes and iron in a pill is commonly resorted to The iron improves 
the blood, and the aloes stimulates and congests the pelvic viscera 
by bringing the blood to the sexual organs. Aloes also seems to 
increase the assimilation of iron in some unknown manner. The 
following pill is often of service, and was especially recommended by 
Goodell : 

fy — Extracti aloes 3J (4.0) 

Ferri reducti 5J (4.0) 

Asafcetidae 3iv (16.0) 

Fiant pilulse, No. c. 

S. — From one to three pills three times a day at each period. 

Cimicifuga has been highly recommended in chronic and appar- 
ently causeless amenorrhea in the dose of 30 minims (2.0) of the 
fluidextract three times a day at the time for a proper flow to occur, 
but corpus luteum in 5 grain (0.3) tablets or capsules is probably the 
best remedy. (See Corpus Luteum.) The dioxide of manganese, in 
the dose of 1 to 3 grains (0.06-0.2), has come prominently forward as 
a remedy in simple idiopathic amenorrhea, and is undoubtedly of 
service, but it should be taken for at least two weeks before the 



ANAL FISSURE 673 

date upon which each menstruation is expected to occur. Potassium 
permanganate is also useful during the same period, but it is inferior 
to the'binoxide of manganese in the author's experience. 

Apiol, the active principle of parsley, may be given in capsules in 
the dose of 3 to 10 minims (0.2-0.6) in the same manner, and the 
oils of rue, savine, and tansy have also been employed in capsule in 
the dose of 5 drops (0.3) three times a day. 

In all forms of amenorrhea a hot sitz-bath at the time for the 
expected "period" is of service, more particularly if the patient has 
"caught cold." The bath should be persevered in for several nights, 
and care should be taken to avoid exposure. Often a little mustard 
added to the water will increase the efficacy of this treatment. 

Under the name of "Dewees's Emmenagogue Mixture," first 
devised by Professor Dewees, of Philadelphia, the following formula 
has been largely used in functional and organic amenorrhea: 

Efc— Tincturae ferri chloridi . f 3iij (12.0) 

Tincturse cantharidis f 5j (4.0) 

Tincturse guaiaci ammoniati f 3iss (6.0) 

Tincturse aloes f 5ss (16.0) 

Syrupi q. s. ad fBvj (180.0).— M. 

S. — Tablespoonful (16.0) three times a day. 

ANAL FISSURE. 

This is one of the most painful affections to which man is subject, 
and requires intelligent treatment, generally by surgical means if the 
result is to be curative, although great relief can be obtained by the 
use of drugs. 

The most annoying feature of the lesion is the intensity of the pain 
on defecation, which is so severe that emptying of the bowel is post- 
poned as long as possible by the patient. 

To relieve this pain and enable the patient to have a fairly comfort- 
able stool, nothing is so good as an iodoform suppository containing 
10 grains (0.6) of the drug, preceded the night before by an enema 
of sweet oil, and retained to soften the feces. Iodoform being a 
local anesthetic, the passage may take place with very little suffer- 
ing. If much spasm of the sphincter is present, extract of hyoscya- 
mus, | grain (0.03), may be added to each suppository. For the cure 
of the fissure a drop of strong phenol may be applied to the spot, and 
a lotion of tannic acid, glycerin, and water used if hemorrhoids are 
also present. Ringer highly recommended the application to the 
fissure, by means of a brush, of a solution of bromide of potassium, 1 \ 
drams to 1 ounce (6.0 : 30.0) of glycerin. In order that the passages 
may be soft and yet the patient not be purged, sulphur may be given 
in the dose of 20 to 40 grains (1.3-2.6) every night, or, if this cannot be 
used, mineral oil may be administered. The best way to give the 
sulphur is by combining it with powdered cinnamon^ or aromatic 
43 



674 DISEASES 

powder. Sometimes relief is obtained by the use of flexible collodion 
painted over the fissure. Pure ichthyol locally applied sometimes 
does good. 

The radical means of cure consist in stretching the sphincter ani 
under anesthesia. This is followed by incising the base of the fissure, 
curetting it, and then touching it with a stick of nitrate of silver. 

ANEMIA. 

It is, unfortunately, only too true that the entire subject of blood- 
making and blood-breaking is as yet very imperfectly understood, but 
many of our therapeutic facts rest on rational ground. Practically 
speaking, the therapeutist recognizes two very important points, the 
causes of which the pathologist must eventually solve— namely, that 
one class of anemias is due to defective or deficient hemogenesis, and 
another to excessive hemolysis. The former is generally believed to 
form the simple class, and the latter the essential or pernicious class. 
It is in the excessive hemolysis class that we most frequently fail to 
produce good results. More than this, the causes of excessive 
hemolysis are so various that we can further divide them into remov- 
able and permanent, the removable being represented by the cases in 
which copremia or auto-intoxication takes place, while the others are 
represented by the true pernicious anemia, about which we know very 
little, save that most observers find evidence of defective hemogenesis 
and of profound hemolysis in the percentage of iron in the liver. 
Unfortunately, it is at present impossible for us to separate clinically 
the anemia of defective hemogenesis from that of hemolytic excess, 
unless we find evidence of great corpuscular disintegration in a copious 
elimination of hemoglobin in the urine, or a jaundice evidently 
hematogeneous in character, or a large number of defective corpuscles, 
which would perhaps indicate defective hemogenesis rather than that 
they were scarred veterans of a battle with a poison in the liver cells 
or elsewhere. Postmortem signs often aid us in the differential diag- 
nosis, but this is too late to be of any benefit to the patient. 

There is one point, however, about which there can scarcely be 
any doubt, and that is that in many cases iron is greatly abused, being 
given when there is no indication for it or more frequently given in 
excessive dose. By excessive dose the author refers to as much as 6 to 
10 grains of reduced iron in a day. The amount of iron in the human 
body is very small, and every study made of its absorption and 
elimination after absorption has shown that these processes are very 
slow. Hamburger recovered from the feces nearly all the iron 
administered, and Jacobi proved that even when the iron was injected 
into the veins 10 per cent, was at once eliminated by the bowels, liver, 
and kidneys, and the remainder deposited in the liver, spleen, and 
other tissues in the same manner as is any metallic substance. The 



ANEMIA 675 

researches of Gottlieb have also been in confirmatory lines. When we 
consider that there is in the human blood only about 39 grains of iron, 
all told, we can see that the use of 12 grains a day in the course of a 
little over three days places a double quantity of the metal in the 
economy, which is not needed, and is either cast out or deposited at 
any convenient spot, there to lie undisturbed until it can be extruded. 

Much, of course, depends upon the cause of the anemia, but there 
is only one excuse for the use of the large doses of iron just named— 
viz., a condition of the digestive apparatus which results in the forma- 
tion of a sulphide of iron in great quantity, so that only an infinitesimal 
amount escapes into the system. This perhaps explains the empirical 
fact that in some cases of chlorosis or intense anemia iron has to be 
given in large doses or hypodermically to accomplish good results. 

One of the best studies on this subject is that of Ralph Stockman, 
who has given us a masterly summary of the subject of the absorption 
in iron in chlorosis. In this summary he points out that we have 
three chief theories as to the action of iron in anemia. The first, the 
absorption theory, is based on the fact that as iron is taken into the 
body with the food, the iron of the hemoglobin must be obtained 
from this source, and therefore that medicinal iron given by the mouth 
must be absorbed. The second theory rests upon the belief that 
iron is not absorbed when given by the mouth in addition to that in 
the food, but simply acts as a stimulant to the mucous membrane of 
the alimentary canal, therefore increasing the digestion of food and 
so overcoming anemia by the general improvement coincident upon 
proper nutrition. This theory is of little value, as it has been proved 
that all forms of iron are absorbed. The third theory is that of 
Bunge— namely, that in chlorotic conditions there exists an excess of 
sulphur or sulphuretted hydrogen in the bowel, which changes the 
iron in the food into a sulphide of iron, which Bunge states cannot be 
absorbed. He believes that the inorganic iron which is given as a 
medicine saves the organic iron of the food by combining with the 
sulphur, and so indirectly cures the anemia by the protection afforded 
the food-iron. It is important to remember that each of these theories 
has been supported by many careful experiments, but it is also well 
to bear in mind that the hypotheses and the experiments supporting 
them may be erroneously based. Thus, we have no right to imagine 
that the inorganic preparations of iron have a stimulating power over 
the alimentary mucous membrane, or, even if they have, that this 
power is exercised in the peculiar line of aiding in the absorption of 
the organic iron of the food. Again, the researches of Hamburger, 
Damaskin, Gottlieb, Miiller, Jacobi, and Socin, which show that after 
the internal use of inorganic iron there is no increase in the iron in the 
urine, are valueless so far as the conclusions drawn by them are 
concerned— namely, that as there is no increase in iron in the urine, 
there is none in the blood, and therefore it is not absorbed. These 



676 DISEASES 

conclusions are not justified, because they are based on the erroneous 
views that because iron is not in the urine it is not in the blood, and 
because it is not in the blood it is not absorbed. Every one knows that 
in the case of chronic lead-poisoning, when the body is saturated with 
the metal, there is often no lead in the urine, the poison being deposited 
in the tissues; and if this is true of lead, it may be of iron. Particu- 
larly is this to be remembered when we find Stockman quoting the 
researches of Mayer, Bidder, and Schmidt, and a host of others, who 
have proved that we are not to look to the kidneys as the path for the 
excretion of iron, but to the intestinal walls. Finally, when iron is 
used hypodermically it cures anemia, although it cannot under these 
conditions stimulate the digestion or combine with sulphides. 

Iron will not cure all cases of anemia, even if they belong to a 
functional type, but other methods must be resorted to at the same 
time or separately for their cure. Reduced iron is the best chalybeate 
for uncomplicated cases. Besides using iron in this form, we should 
employ laxatives if the bowels are confined; mineral acids, particularly 
nitric and nitrohydrochloric, for their effect on the function of the 
small intestine and liver; and in addition, bitter tonics of a more or 
less simple form, according to the exigencies of the case, using quinine 
or simple bitters if the stomach lacks tone, aromatic bitters if the 
digestive tract seems sluggish from atony of the muscular coats, 
with a resulting formation and accumulation of flatus and lack of 
digestive juices. 

The preparations of iron best employed in anemia are the insoluble 
salts just named, such as reduced iron or the carbonate, but there 
are indications for each salt which must be regarded. In many 
anemic persons, particularly females, the tongue is broad and white, 
not from coating, but pallor— is flabby and torpid looking. Under 
these circumstances the bowels should be kept moving by mild purges, 
and a bitter tonic like calumba and an acid preparation of iron be 
taken by the patient. In the anemia caused by rapid childbearing 
and lactation, cod-liver oil, with iron and quinine in tonic dose may 
be also of service. With some practitioners Blaud's pill is very much 
used, made as follows: 

1$ — Ferri sulphatis exsiccati, 

Potassii carbonatis aa 5ij (8.0) 

Syrupi q. s. — M. 

Fiant pilulse, No. xlviii. 

S. — One to three pills three times a day, after meals. 

In cases of marked secondary anemia, in which the broad, flabby 
state of the tongue indicates poor absorbent power of the alimentary 
tract, and in pernicious anemia, citrate of iron may be given intra- 
muscularly with advantage. It is best given by use of sterile ampoules 
containing about \ grain (0.02) once or twice a week. (See Iron.) 

Inunctions of very small amounts of mercurial ointment once a day 
or every other day, in adults and in children, will increase the fulness 



ANEURISM 677 

and redness of the cheeks and lips and the number of the corpuscles, 
the piece of ointment used being no larger than the half of a very small 
pea. This treatment will be found of service in cases not necessarily 
dependent upon specific taint. The marked increase in the nutrition 
of children of a syphilitic taint who are suffering from marasmus under 
the internal use of gray powder and full inunctions of mercurial oint- 
ment is most extraordinary. 

Arsenic is of particular merit in those forms of anemia in which 
the blood-cells are lacking in number rather than in hemoglobin. 
Any one of the preparations of arsenic may be employed, and should 
the anemia be pernicious in its type, or should it depend upon 
leukemia or pseudoleukemia, the arsenic must be pushed in ascending 
doses until marked evidences of its general effects are manifested 
and for this effect the cacodylate of sodium in the dose of 1 to 2 grains 
(0.06-0.12) may be given hypodermically every other day until 
diarrhea, renal irritation or a garlic odor of the breath develops. 

In pernicious anemia the treatment and prognosis depend to some 
extent upon the blood picture under the microscope. In cases which 
are fairly favorably there will be evidence of efficient bone marrow 
activity in the increase in the number of young red cells (reticulated 
cells), in an increase in the polymorphonuclear leukocytes and in the 
blood platelets, whereas a diminution in these cells indicates an 
inactive bone marrow particularly in the case of the platelets. In 
the latter type arsenic is indicated in full doses, and in some cases 
moderate transfusion to compensate for the destroyed blood, but so 
far as results from treatment are concerned, either from arsenic or 
transfusion, the best occur in those cases with an active bone marrow 
because the fundamental state of the patient is not so evil. 

In those types of pernicious anemia in which hemolysis is a domi- 
nant factor, in which the skin is yellow and the spleen enlarged, 
splenectomy is indicated, particularly if the blood picture is one of 
fair bone marrow activity since by this means it is hoped to arrest 
hemolysis and permit the bone marrow to make up for the cells here- 
tofore rapidly destroyed. When the transfusion is used one should 
not wait until relapse occurs but the blood should be watched and if it 
falls only a little in cells and hemoglobin the operation should be 
repeated. 

Diet is an important part of the treatment of anemia. The food 
should be good, well flavored, and varied, as well as easy of digestion. 
It should contain, as far as possible, the remedies needed by the 
system, such as bone salts and iron, and its ingestion may be accom- 
panied by some red wine, such as port. Sunshine and fresh air are 
also essential. 

ANEURISM. 

The treatment of aneurism by drugs is not very successful, but is 
at least worthy of trial in all cases. Vascular disease resulting in 



678 DISEASES 

such a lesion depends upon so many causes which may modify the 
treatment that the history of the case should be carefully considered. 
The most common causes are traumatism and syphilis, and very 
often injury is superimposed upon systemic infection. Whatever the 
cause of the disease may be, iodide of potassium is par excellence the 
remedy most apt to do good, even if it does not cure. The doses 
should be large, 30 to 60 grains (2.0-4.0) three times a day if the 
patient will bear them, and the prognosis under this treatment is far 
more favorable if the cause be syphilis than if the disease be idiopathic 
or traumatic. 

For successful treatment the recumbent position must be insisted 
upon, the patient being kept quiet in bed, changing his position as 
little as possible and confining himself to the most simple and easily 
digested diet, with entire avoidance of all stimulating substances 
either in the way of food or drink. Often it is best to adhere to an 
absolute milk diet. If the heart is excitable and irregular in its 
action, the vascular system irritable, and a high arterial tension is 
present, the circulation must be quieted by small doses of tincture of 
veratrum, say 4 to 8 minims (0.25-0.5) twice or thrice a day, but 
digitalis is not to be employed, since it increases the strain upon the 
aneurismal sac, although it quiets the irregular heart beat. Aconite 
may also be used in full doses. If the pain be very great— and it 
often is severe, particularly at night— opium is indicated, and sleep- 
lessness should be allayed, not by full doses of morphine alone, but by 
morphine and chloral. All attempts to cure aneurism by the use of 
other drugs, unless syphilis indicates mercury, are useless when the 
lesion is thoracic or abdominal; and when it occurs in the extremities, 
as in popliteal aneurism, pressure or surgical measures are to be 
resorted to as the chief means of cure. If dyspnea is marked in 
thoracic aneurism, slight inhalations or " whiffs" of chloroform are 
sometimes useful, as is also morphine, given hypodermically in the 
dose of i grain (0.008). 

When a sacculated aneurism develops in the thoracic or abdominal 
aorta and is of good size, the best treatment is the introduction of gold 
wire, and the aiding of clot formation by electrolysis. The operation 
consists in pushing a hollow insulated needle into the sac, and then 
passing through it from 30 to 50 feet of fine gold-platinum wire, fed 
from a spool, so that it coils in the cavity. The external end of the 
wire is attached to the positive pole of the battery, and a large clay 
electrode is attached to the negative pole and placed under the back. 
The current is gradually turned on and increased, during a period of 
fifty minutes, from 5 to 40 milliamperes. The wire is then cut off, 
the needle removed, and the operation is finished. No accident 
during the operation has been reported when properly performed. 
It is absolutely contraindicated in fusiform aneurism. The first 
result is relief of pain, usually before the operation is completed. The 
second result is arrest of the growth, even when the skin over it seems 



PLATE IV 



p^tfr^j'A^M 


p^jjl 












n ty '.A 


£JL?/fl « 








..-." 3S ' 'J 




f j| 






B&. • 1 






■i 


, 






4 




f ] 




V 1| 









Showing the manner in which the wire is coiled in an aneurism of 
the ascending arch. The specimen is not only split vertically but cut 
transversely and the anterior wall lifted and turned back. Most of the clot 
has been removed to show the wire. In the centre of the aorta is shown 
the small orifice which opened into the sac. 



PLATE V 




Skiagraph showing Wire Coiled in Aneurysmal Sac from a 
Patient in the Author's Wards. 

Case reported by Dr. Beardsley 



AXGIXA PECTORIS 679 

about to give way. The third result is prolongation of life in hopeless 
cases for weeks or years. The writer has performed this operation 
a large number of times with satisfactory results, although when the 
growth was very large and the aorta severely diseased, the inevitably 
fatal result was postponed a comparatively short time, because the 
sac enlarged in another direction and ruptured or caused death by 
pressure on vital tissues. (See Plates IV and V.) 

ANGINA PECTORIS. 

The exact pathological changes existing in angina pectoris are by 
no means clearly understood, but without doubt many attacks are due 
to spasm of the bloodvessels, which results in distention of the left side 
of the heart, which organ is already dilated or enfeebled by dis- 
ease. Often, too, the coronary arteries have undergone degenerative 
changes, thereby increasing the cardiac debility. Remedies which 
ordinarily relieve pain act too slowly or too feebly to be of service in 
angina pectoris, and even if successful would only relieve the symptom 
without removing the cause. The indication when the blood-pressure 
is high is to relax the vascular spasm, thus relieving the overburdened 
heart. As first pointed out by Brunton, the nitrites possess this 
power, and to him belongs the credit of first applying this class of 
drugs to this ailment. All the nitrites are useful, but the nitrite of 
amyl and nitroglycerin are the best remedies for the attack itself, and 
the nitrite of potassium or sodium for the intervening periods or when 
the paroxysm is prolonged. The reason for this lies in the fact that 
the sodium and potassium compounds are more stable than the other 
two compounds, are more slowly broken up in the body, and therefore 
more prolonged in their effects. In an attack a few drops of the 
nitrite of amyl should be given by inhalation from a handkerchief, 
or the nitroglycerin can be used in the dose of 1 to 2 minims of the 
official Spiritus glycerylis nitratis hypodermically. The dose of the 
sodium and potassium nitrites is 1 grain (0.03) five times a day, but 
all these drugs are useless unless the arterial tension is high or the 
action of the heart labored. 

It is often well to give the patient one of the following prescrip- 
tions to ward off a threatened attack or even to relieve a mild one 
already in existence: 



Or, 



1$ — Spiritus chloroformi, 

Spiritus ammoniae aromatici aa f5j (30.0). — M. 

S. — A dessertspoonful (8.0; in 2 ounces (60.0) of water p. r. n. 

]} — Spiritus chloroformi, 

Tincturse lavendulae compositse . . . . aa f5j (30.0). — M. 
S. — Same dose as above. 



Whisky or brandy are useful in full dose, in warm water. Ether 
given hypodermically is often of service, or Hoffmann's anodyne may 



680 DISEASES 

be used instead of ether by the mouth or hypodermically with good 
results. Digitalone in the dose of half a grain (0.03) may be given 
hypodermically during the attack to stimulate the heart if it is 
weak, and by the mouth, between the attacks, to improve its con- 
dition. 

If the nitrite does not relieve the pain, or if it cannot be used because 
of some contraindication, morphine must be given hypodermically 
in the dose of J to J grain (0.015-0.03), but it should never be given 
by the mouth under these circumstances, as its absorption will be too 
slow and its effects will come on after the pain has ceased. 

The prevention of future attacks rest upon the elimination of all 
causes which can possibly produce a nerve-storm and cardiac irri- 
tability, and in the administration, if the arterial tension is high, of 
nitroglycerin or one of the other nitrites in full dose for long periods of 
time. (See Sodium Nitrite, Part II.) As a rule, these drugs have to 
be gradually increased in dose in order to maintain their effect. Full 
doses of one of the iodides, particularly Donovan's solution, continued 
over a long period of time are useful. 

The following is a valuable prescription for use between the attacks 
if the heart is feeble and the tension high : 

3— Tincturae digitalis ■ . f 3j (4.0) vel f 3iij (12.0) 

Tincturse belladonnas f Sss (15.0) 

Spiritus glycerylis nitratis .... Tfl.xxiv (1.6) vel f 3J (4.0) 
Tincturse cardamomi f Siij (90.0). — M. 

S. — Teaspoonful (4.0) three or four times a day. 

The diet should be moderate and easy of digestion, and salads, 
lobster, and similar articles of food avoided. If the patient is inclined 
to take exercise of a violent character he must be restrained, but, on 
the other hand, some gentle exercise may be permitted if it is possible 
to take it without precipitating an attack. 

Tonics, fresh air, freedom from mental worry, and avoidance of 
exposure to cold are also necessary, and running for a car, or per- 
forming any act calculated to suddenly increase arterial pressure and 
cardiac work, is to be avoided. 

In that form of heart pang occurring in nervous females, some- 
times called pseudo-angina pectoris, 1 dram (4.0) of ether in ice-water 
or capsules will often abort the attack, or one of the prescriptions 
containing spirit of chloroform, given above, or if the paroxysm is 
caused by dyspepsia and if the stomach be overloaded, the sufferer 
may be relieved by an emetic or the stomach-pump. 

ANOREXIA. 

Anorexia, or lack of appetite, is only a symptom of ill health, gen- 
erally associated with debility or other systemic disorder, such as 
anemia, fever, and many exhausting diseases. It is best treated by 



APOPLEXY 681 

a well-cooked and daintily prepared diet, the use of the bitter tonics, 
such as gentian, cardamoms, and the mineral acids, or by the use of 
one of the following prescriptions : 

3— Arseni trioxidi gr. §(0.03) 

Extracti nucis vomicae gr. iv (0.25) 

Quininse sulphatis gr. xx (1.3). — M. 

Fiant pilulae, No. xx. 

S. — One t. i. d. after meals. 



Or, 



1$ — Acidi hydrochlorici diluti f5ss (16.0) 

Tincturse cinchonas composite f 5vj (180.0). — -M. 

-Dessertspoonful (8.0) three times a day, after meals, well diluted with water. 



(For the use of other bitter tonics see Calumba, Quassia, Chamo- 
mile, Cardamom, and Nux Vomica. None of these drugs is suitabl- 
if there is any acute irritation or inflammation of the stomach or intese 
tines.) (See Indigestion.) 

APOPLEXY. 

Up to a recent period it has been held that the high arterial tension 
of apoplexy was evil in its effect because it increased the extravasation 
of blood through the leaking vessel, and for this reason venesection has 
been commonly employed. Studies carried on by Kocher, in Berne, 
and by Gushing, this country, seem to indicate that this high arterial 
tension is an effort of Nature to drive sufficient blood into the cranium 
to maintain the circulation in the brain, which would otherwise be 
impaired by the pressure of the extravasated fluid, for great inter- 
cranial pressure depresses the vasomotor centers and with its failure 
the vital centers nearby fail to receive an adequate supply of blood. 
Some surgeons have advocated opening the cranium and removing 
the clot. The objection to this plan is that the soft tissues of the brain 
have been irreparably damaged by the rushing of the blood from the 
ruptured vessel. The condition is quite different from that found in 
meningeal hemorrhage. 

With our present knowledge it is probably best to use measures 
which are helpful and not radical. 

Hot mustard plasters may be applied to the feet, or a hot mustard 
foot-bath be used if this is practicable. Ice in an ice-bag or wrapped 
in a towel may be applied to the head. If vomiting comes on, care 
must be taken that the stertorous breathing does not draw into the 
lungs particles of the half-ejected food. Sometimes croton oil, 1 
minim (0.05), placed on the tongue with 20 minims (1.3) of sweet oil 
may cause a depletant catharsis which will relieve cerebral engorge- 
ment, or i grain (0.01) of elaterium may be used. The head must 
be kept high and the feet low. These are the methods to be used 
immediately after the rupture of the bloodvessel. 



682 DISEASES 

The objects to be sought, after the " stroke" has occurred and the 
hemorrhage has ceased, are the removal of the extravasated blood, the 
restoration of function in the paralyzed parts, and the prevention of 
secondary lesions consequent upon inflammation of the brain as a 
result of the injury to its substance. If the patient survives the 
attack, no drugs should be used for several days, until the clot in 
the ruptured vessel has become firmly fixed, unless symptoms of cere- 
britis arise, when vascular sedatives, such as aconite, must be pushed 
if the pulse is tense, and calomel administered in small doses, \ grain 
(0.015) every four hours. After the clot has firmly formed and 
has plugged the leak in the bloodvessel, we may proceed to take 
measures for the absorption of the exudate, the chief measures con- 
sisting in the use of iodide of potassium in as large doses as the patient 
will bear without the production of iodism. This drug should not 
be resorted to until two or three weeks have elapsed after the attack. 
Mercury in small doses may also be given, particularly if an old 
syphilitic infection is the underlying cause of the vascular rupture. 

In order that the muscles of the extremities may not waste and 
become powerless from disuse, passive exercise, rubbing, and, if pos- 
sible, massage, must be resorted to. Electricity may be applied to 
them in the form of the slowly interrupted current, and strychnine 
may be used hypodermically or by the mouth as a stimulant to the 
trophic centers in the spinal cord. None of these measures is to be 
employed if any inflammation exists in the brain, as they will increase 
the cerebral disorder, and at least three weeks should elapse after the 
attack before they are resorted to. (See Strychnine.) 

Electricity applied to the head is useless, as the current does not 
go through the brain, but around the skull by means of the scalp. 

A very careful diet is to be maintained. Meats are to be used very 
sparingly, the bowels maintained in perfect regularity, and no wines 
are to be taken nor any stimulants used lest they cause a second 
rupture of the weakened vessel in the brain. 

Apoplexy must be carefully differentiated from acute alcoholism and 
opium-poisoning, which it much resembles. (See Alcohol.) 

If respiration fails, nothing can be done with much advantage, but 
atropine or strychnine may be given hypodermically. The use of 
electricity to stimulate the phrenic nerve and diaphragm when respira- 
tion fails is a remnant of senseless medical practice, and is particularly 
useless in apoplexy. (See Asphyxia.) 

Above all things, stimulants are contraindicated during the acute 
attack, even though the pulse fails, as they increase the hemorrhage 
into the brain. 

If the symptoms of apoplexy are produced by an embolus or throm- 
bus, bleeding is useless, and it may be harmful by decreasing arterial 
pressure and thereby delaying the establishment of collateral circula- 
tion. This is also true of circulatory sedatives. 



APPENDICITIS 683 



APPENDICITIS (ACUTE), 



It is to be remembered that many cases which years ago would have 
been called idiopathic peritonitis are now recognized as arising pri- 
marily from inflammation of the appendix vermiformis. For this 
reason it is incumbent upon every physician who is called to see a case 
of abdominal, or right-sided lower thoracic, pain to examine carefully 
into the condition of the appendix. No routine treatment for appen- 
dicitis can be followed, as each case possesses distinct individuality. 
There are many surgeons, holding extreme views, who assert that the 
mere presence of appendicular inflammation for a few hours renders 
an extirpation of this organ necessary. There is good reason for this 
view because very frequently the diseased organ is removed before it 
has done harm or one is startled at finding on opening the belly that 
the appendix is just about to perforate or rupture or is already 
gangrenous. For these reasons there are doubtless many cases in 
which the physician postpones consultation with a surgeon until it is 
too late to save the patient. On the other hand, many cases of acute 
appendicitis get well without operation. (See below.) 

It is unwise to give a purgative, since the caput coli never contains 
feces in any quantity, and, furthermore, in those fairly severe cases 
which demand operation at once the possibility of perforation of the 
appendix, with escape of the contents of the bowel into the peritoneal 
cavity, is always to be remembered. Intestinal rest is essential, 
which is the probable explanation of the confidence of our fore- 
fathers in opium in peritonitis. 

If the patient shows definite tenderness on pressure over McBurney's 
point, has a quickened pulse-rate with distinct, but not necessarily 
marked, fixation of the abdominal wall on the right side, and has a leu- 
cocytosis of 15,000 to 25,000, even if the temperature is not raised, 
advise operation if a surgeon skilful enough to do it well and ex- 
perienced enough to meet unexpected complications can be had. If 
there is a history of severe pain followed by relief without the use 
of opiates, operate, because the relief is probably due to gangrene or 
perforation. 

Also recall that a retro-colic appendix may cause pain which is 
posterior or high up. 

If the patient has been ill some days and diffuse peritonitis has 
developed, operation is to be postponed until the inflammation sub- 
sides or is localized, and the treatment described under Peritonitis 
instituted. Sometimes it is best to postpone surgical interference in 
mild cases until after the acute attack is over, but the difficulty lies 
in the fact that sometimes cases presenting mild symptoms are 
actually severe and slough early. If there is a history of other attacks 
it is best to operate, even if the symptoms are mild. 

In all cases of appendicitis in which operation is refused or in which 
it is not possible to get the aid of a competent surgeon, the method to 



684 DISEASES 

be followed is briefly as follows: The patient is to be put to bed 
and absolute rest on the back insisted upon. He must not rise to 
the sitting posture even for defecation or urination. No food or 
drink should be given for twenty-four or thirty-six hours, in order 
that the greatest degree of intestinal rest may be attained. If con- 
stipation has been present so that the bowels are loaded with feces, 
it is best to unload the colon by a rectal injection. After the bowels 
have been moved, sufficiently large doses of opium or morphine are to 
be given to relieve pain if it is severe enough to be agonizing. The 
doses should be so small as to only "take the edge off the pain," but 
they must not stupefy the patient, so that he fails to give clear 
answers to questions or is so comfortable that in his ignorance he 
declines surgical aid. Proctoclysis should be resorted to. (See 
Peritonitis.) 

The whole question as to operation depends upon the severity of 
the inflammatory process, the medical attendant's ability to deter- 
mine its severity, the state of the patient (see Peritonitis) and not 
least, upon the ability to obtain first-rate surgical skill in the operator. 
Richardson believed that if the operator is inexperienced the patient's 
chances are best from medical treatment. 

In this connection it is of interest to consider the plan instituted by 
Ochsner, and which has given results which demand attention. The 
determination of the character of the treatment to be carried out rests 
upon the condition of the appendix at the time the patient is seen. 

His views are best described as follows: 

1. Patients suffering from chronic recurrent appendicitis should be 
operated on during the interval. 

2. Patients suffering from acute appendicitis should be operated on 
as soon as the diagnosis is made, provided they come under treat- 
ment while the infectious material is still confined to the appendix, if a 
competent surgeon is available. 

3. In all cases of acute appendicitis without regard to the treatment 
contemplated the administration of food and cathartics by mouth 
should be absolutely prohibited and large enemata should never be 
given. 

4. In case of nausea or vomiting or gaseous distention of the abdo- 
men, gastric lavage should be employed. 

5. In cases coming under treatment after the infection has extended 
beyond the tissues of the appendix, especially in the presence of begin- 
ning diffuse peritonitis, conclusions 3 and 4 should always be followed 
until the patient's condition makes operative interference safe. 

6. In case no operation is performed, neither nourishment nor 
cathartics should be given by mouth until the patient has been free 
from pain and otherwise normal for at least four days. 

7. During the beginning of this treatment not even water should be 
given by mouth, the thirst quenched by rinsing the mouth with 
cold water and by the use of small enemata. Later small sips of very 



ASPHYXIA 685 

hot water, frequently repeated, may be given, and still later small sips 
of cold water. There is danger in giving water too freely. 

8. All practitioners of medicine and surgery, as well as the general 
public, should be impressed with the importance of prohibiting the 
use of cathartics and food by mouth, as well as the use of large ene- 
mata, in cases suffering from acute appendicitis. 

9. It should constantly be borne in mind that even the slightest 
amount of liquid food of any kind given by mouth may give rise to 
dangerous peristalsis. 

10. The most convenient form of rectal feeding consists in the use 
of one ounce of one of the various concentrated liquid predigested 
foods, dissolved in three ounces of warm normal salt solution, intro- 
duced slowly through a soft catheter inserted into the rectum a dis- 
tance of two or three inches. 

11. This form of treatment cannot supplant the operative treat- 
ment of acute appendicitis, but it can and should be used to reduce 
the mortality by changing the class of cases in which the mortality is 
greatest into another class in which the mortality is very small after 
operation. 

To this plan the author would add the use of normal saline solution 
by hypodermoclysis, with the object of allaying thirst and flushing the 
kidneys. (See Enteroclysis in article on Peritonitis, Important.) 

The patient should be placed in the so-called Fowler's position, 
that is semirecumbent, and kept there to aid in the prevention of the 
spread of infection toward the diaphragm. 

ASPHYXIA. 

When practising artificial respiration in cases of asphyxia the 
so-called "prone-posture method" of Schafer or Sylvester's method 
should always be employed. 

Schafer's method consists in placing the patient so that he lies on 
the anterior aspect of the body, with the face turned to one side. 
The physician then kneels at one side or astride of the patient and, 
placing his hands on the floating ribs, so that the heel of the hand rests 
at about the posterior axillary line, presses upon the thoracic walls, 
which drives out the air from the chest and also any fluid or mucus 
which may be blocking the upper respiratory passages. The pressure 
is then removed and the natural elasticity of the chest wall causes 
inspiration. The movements should be made about fourteen times 
a minute. 

Sylvester's method consists of laying the patient on some hard, 
flat surface, kneeling above his head, and then, after grasping the 
arms at the elbows, bringing them upward and outward, so that they 
follow the plane on which the body is extended. This movement 
causes expansion of the chest, or inspiration. After a moment's pause 
the arms are lifted up and brought toward one another, and then 




Fig. 119. — Artificial respiration by Schafer's method. By this means fluids and 
mucus are more readily expelled from the upper respiratory tract than in the older 
methods. 




Fig. 120. — Sylvester's method of artificial respiration. First movement: the 
patient's arms are placed at right angles to the trunk, the elbows resting on the floor, 
to expand or inflate the chest. 




Fig. 121. — Sylvester's method of artificial respiration. Second movement: the 
patient's arms are drawn toward the physician, in order to expand the chest still 
further. 



ASPHYXIA 687 

while still approximated, pushed down near to their original position 
upon the floating ribs, upon which they are pressed. This last move- 
ment drives out the air from the chest, or causes expiration. These 




Fig. 122. — Sylvester's method of artificial respiration. Third movement: the patient's 
arms are raised and the elbows approximated to contract the chest. 

movements should be at the rate of from sixteen to twenty per 
minute, about that of normal respiration, and be persisted in for at 
least forty-five minutes, even though the case seems hopeless, as cases 
have recovered after as long a period of apparent death as an hour. 
While these movements are being carried on the patulousness of the 




Fig. 123. — Sylvester's method of artificial respiration. Fourth movement: the 
patient's elbow and forearms are pressed forcibly upon the floating ribs to expel the 
air from the chest. 

upper air-passages is to be maintained, if possible, by the measures 
described below. The disadvantages of Sylvester's method are that 
the posture of the body does not drain the upper respiratory passage 



688 



DISEASES 



of fluid and, further, it rapidly exhausts the operator, since the arms 
of an unconscious patient are very heavy and difficult to move. 




Fig. 124. — Showing the attitude in which the head should be held to permit the 
easy passage of air through the glottis. This position raises the epiglottis and lifts the 
soft palate from the tongue. (Martin and Hare's method.) 

The Proper Position of the Head.— In some researches made by 
Dr. Martin and the writer the following rules regarding the position 
of the head, neck, epiglottis, and tongue were formulated: The 




Fig. 125. — Illustrating how upward traction on the tip of the tongue draws the epi- 
glottis away from the glottic opening and permits free ingress of air. It also shows 
how letting the tongue fall back in the mouth in anesthesia would close the air-passages 
and permit the epiglottis to interfere with breathing. (From a research by Dr. Martin 
and the author.) 



fingers are passed behind the angles of the lower jaw and the latter 
is pressed forward; this elevates the epiglottis and the base of the 



ASTHENOPIA 689 

tongue about a quarter of an inch from the postpharyngeal wall. 
Extending the head and pushing it forward, so that the neck makes 
an angle of forty-five degrees with the plane of the table, draws the 
base of the tongue and the hyoid bone far forward, this motion being 
at the- same time imparted to the epiglottis, so that the latter stands 
upright and is separated from the posterior wall of the pharynx by an 
interval of about an inch. By tightly closing the jaw the antero- 
posterior space is still further increased (Fig. 124). 

A very useful method of treating asphyxia is that of Laborde, by 
rhythmic traction on the tongue. The tongue is grasped with forceps 
and pulled well forward and upward from ten to fourteen times a 
minute until voluntary respirations occur. The sensory nerves of the 
tongue carry impulses to the phrenic center, which in turn causes the 
diaphragm to contract. A very large number of recoveries from 
apparent death as a result of its use renders this method most worthy 
of trial. 

The absurdity of the application of the rapidly interrupted electric 
current to the phrenic nerve is not alone dependent upon the points 
we have named. (See Ether.) It has been proved by careful obser- 
vation on the part of Dr. Edward Martin and the author that the 
application of the electrode over the phrenic nerve in the neck may 
cause cardiac arrest through diffusion of the current to the vagus 
nerve, and Griswold reached conclusions of an identical character in 
1885. 

If electricity is used, it should be employed solely as a peripheral 
irritant, with the subject of arousing the patient, as would the dry 
electric brush. 

ASTHENOPIA. 

Asthenopia, or weak sight, depends upon exhaustion of the power 
of accommodation in cases of refractive error, usually hypermetropia, 
or upon imbalance of the external ocular muscles. The former is 
sometimes called accommodative asthenopia, and the latter muscular 
asthenopia. The treatment of these conditions requires the prescrib- 
ing of proper lenses, combined, if necessary, with prisms and with 
systematic exercise of the ocular muscles. Locally, a weak solution 
of the sulphate of eserine or pilocarpine acts as a stimulant to the 
ciliary muscle, and good results follow the internal use of large doses 
of the tincture of nux vomica or strychnine. 

I^ — Eserine sulphatis gr. ^ (0.016) 

Aquse destillatse fgj (30.0).— M. 

Or, 

1$ — Pilocarpine nitratis gr. oV (0.003) 

Aquse destillatse fgj (30.0).— M. 

S. — 2 drops (0.1) night and morning. 

Another form of asthenopia is termed neurasthenic asthenopia, or 
retinal anesthesia, and presents a number of eye-symptoms in con- 
44 



690 DISEASES 

nection with a general depression or debilitated state of the nervous 
system, the eye itself, however, being a healthy organ. The chief 
symptoms are fluctuation in visual acuteness, rapid disappearance of 
objects looked at, contraction of the field of vision, imperfect retinal 
images, often associated with dread of light. Correction of refractive 
error is an essential procedure, but is not sufficient. The patient 
requires the same general treatment that would be applied to any 
neurasthenic case. All the functions of the body must be carefully 
examined into and placed in as normal a condition as circumstances 
will allow. Especially valuable are rest, massage, salt baths, and full 
doses of strychnine, together with iron if there be anemia. 

ASTHMA. 

Asthma is one of the most difficult diseases to treat successfully that 
the physician has to deal. 

The disease in all its forms depends upon interference with the free 
entrance to and exit of the air from the lungs, and this is generally, if 
not always, dependent upon a spasm of the muscular fibers in the 
walls of the bronchial tubes with an associated swelling or hyperemia 
of the bronchial mucous membrane. Both of these states are prob- 
ably present in varying degree in all cases. 

The spasm has been proved by Longet, Williams, Romberg, Paul 
Bert, Bierner, and more recently by Sandmann, to be due to a neu- 
rosis of the pneumogastric or vagus nerve, and the swelling of the 
mucous membrane has been seen by Stoerk and others. Thus two 
schools of teaching concerning the pathology of this disease have been 
formed, when a little attention to the physiology of the subject would 
at least show that no difference need exist, for the vagus nerves govern 
not only the muscular fibers, but also the bloodvessels of the bronchial 
tubes. The discovery of Michaelson that injury of the recurrent 
laryngeal nerves causes catarrhal inflammation of the bronchial tubes, 
particularly those of the upper lobes, renders the analogy between 
acute asthma and laryngeal spasm, which has been spoken of by many 
writers, still more interesting. 

One other step remains for a thorough understanding of the man- 
ner in which the disease is produced. Gastric, dyspeptic, or intestinal 
asthma arises from indigestion, as its name implies, and is caused by 
the irritation of the afferent filaments of the vagus in the walls of the 
stomach and intestine, thereby causing reflexly a contraction and 
hyperemia of the bronchial tubes. In a similar reflex manner abnor- 
mal conditions of the nasal mucous membranes in general may result 
in an asthmatic attack. There is also some evidence that small 
collections of pus in the nasal sinuses may reflexly cause asthma, or 
by the absorption of the pus the asthma may be a form of anaphylaxis. 

Closely associated with this type is that which is induced by sensi- 
tiveness of the patient to other forms of proteins than those derived 



ASTHMA 691 

from pus such as the proteins derived from pollens (see Pollen Proteins) 
and food proteins which may come from the animal or vegetable 
kingdom. Many cases of asthma can be relieved or cured by dis- 
covering the source of the protein to which the patient is sensitive 
and avoiding it, or by a course of treatment with small doses we may 
develop an immunity. This book is not the place to discuss this 
subject in extenso. " The point to be remembered is that asthma is a 
symptom not a disease, and that while relief is to be found more or less 
in drugs the cure rests in discovering, if possible, the cause. 

Having obtained some idea of the cause of an attack, let us turn to 
the treatment of the affection. 

As soon as the patient is seen 5 to 10 minims (0.3-0.65) of adrenalin 
solution (1 : 1000) should be given hypodermically; in other cases the 
same amount of pituitrin may be used. They act by relaxing the 
bronchial muscular fibers. If they fail, which is rarely the case, 
morphine hypodermically in the dose of J to J grain (0.01-0.015), 
alone or in combination with atropine, should be resorted to. 

One of the most serviceable remedies in asthma is belladonna, 
which, as has been pointed out when that drug was studied (see Bella- 
donna), exercises in medicinal dose a decided sedative and depressant 
influence on the peripheral filaments of the vagus nerves, not only so 
far as the heart is concerned but also through the pulmonary fibers, 
upon bronchial secretion, which is always diminished by the drug, 
probably by its vagal influence. 

It is evident, therefore, that the use of belladonna or atropine, 
although originally employed in an empirical manner, rests upon a 
rational basis, and as the physiological action of stramonium, hyoscy- 
amus, and similar members of this group is nearly identical with that 
of belladonna, their influence for good is also explained. The experi- 
ments of Ott prove that lobelia is a peripheral pneumogastric depres- 
sant, and those of Rosenthal and the author likewise showed that 
tobacco has a similar effect. The same is also true of nitrite of amyl 
and the other nitrites, which also relax unstriped muscular fiber. We 
have before use, therefore, a list of the most efficacious and best anti- 
asthematics, all of them being depressant to the peripheral vagi. 

The use of amyl nitrite by inhalation, 3 to 6 minims (0.2-0.4) on 
a handkerchief, is invaluable in many cases, and it rarely fails to 
relieve the spasm. Owing to the engorgement of the heart conse- 
quent upon the embarrassment of respiration, this nitrite must be 
used with care. A hypodermic injection of y^ grain of nitroglycerin 
is better. 

The other remedies commonly employed are chloroform by inhala- 
tion, which relaxes the spasm of muscular fiber by its local influence, 
and morphine, which acts as a nervous sedative, prevents reflex irri- 
tation, and quiets the patient, acting at the same time as a heart 
stimulant and unloading the engorged cardiac cavities. Chloroform 
is, however, not devoid of danger, particularly in chronic cases which 



692 



DISEASES 



emphysema and a weak right heart. The relief obtained by the 
inhalation of the fumes of nitrate of potassium, See asserts, depends 
upon the formation of the protoxide of nitrogen and carbonic acid 
gas, which act as local anesthetics. 

Cigarettes made of paper soaked in a solution of nitrate of potas- 
sium and belladonna may be smoked (see formula under Belladonna), 
or they may be made in the following manner: 



1$ — -Belladonnse foliorum 
Hyoscyami foliorum 
Stramonii foliorum 
Extracti opii . 
Aquae laurocerasi . 



gr. vj (0.4) 
gr. iij (0.2) 
gr. iij (0.2) 
gr. | (0.015) 
q. s. — M. 



These various leaves are broken up like commercial tobacco, and 
moistened by adding the cherry-laurel water, which should contain 
the opium. Finally, a whole leaf soaked in the same fluid is used as 
a cover, or a piece of cigarette paper may be employed in the same 
manner. 

In some cases a very useful treatment is the smoking of nitre-paper 
cigarettes, which are prepared, before rolling, not only by soaking the 
paper in a solution of nitrate of potassium (see Nitrate of Potassium) , 
but also by dipping them, after drying them, in tincture of belladonna 
or stramonium, and allowing the alcohol to evaporate from the paper 
while it is hung in the air. 

Another remedy for the relief and cure of asthma is euphorbia 
pilulifera, the fluidextract of which may be given in the dose of \ 
to 1 dram (2.0-4.0) once, twice, or thrice a day. (See Euphorbia 
Pilulifera.) 

The author finds the following formula very useful in asthma : 



1$ — -Sodii iodidi 

Potassii bromidi 

Fluidextracti euphorbiae pilulifera? 

Nitroglycerini 

Tincturae lobeliae 

Fiat tabella vel capsula No. 1. 

S. — From 1 to 4 three times a day. 



gr. ij (0.12) 
gr. ij (0.12) 
miij (0.2) 
gr. yfo (0.0003) 
TUiv (0.25).— M. 



If desired, this formula may be given in the form of an elixir. 

It will be seen that each ingredient of this recipe has a different 
action. The action of the iodides in asthma is well known, as is also 
that of the bromides. The euphorbia pilulifera has been found useful 
in asthma empirically. The nitroglycerin depresses the peripheral 
ends of the vagus nerves, and acts as a stimulant to the heart when 
engorged with blood by removing the inhibitory action of the vagus 
and relieving the blood vessesl elsewhere. The tincture of lobelia acts 
as a depressant to the vagus also. 

A valuable prescription for asthmatics to take between the attacks, 
particularly in those cases which have cardiac symptoms, is the one 
calling for digitalis, strophanthus, and nitroglycerin. 



ASTHMA 693 

Sometimes a cup of strong coffee taken at the beginning of a par- 
oxysm will abort it. 

Sometimes tobacco may be smoked, and it is particularlyefficacious 
in those who are not accustomed to its constant use. 

Lobelia when employed should be used in full emetic dose (2 
drams [8.0]), in the form of the tincture if an attack is imminent. 
If an attack is feared, 20 minims (1.3) of the tincture every four 
hours may be given if the heart is in good condition. 

A treatment of asthma which is very successful when it arises from 
a focus of irritation in the nose consists in the application to the 
sensitive spot at the onset of the attack of the following solution by 
means of a brush or spray: 

1$ — Cocainse hydro chloridi gr. xv (1.0) 

Aquae destillatae q. s. ad f 3iv (16.0).— M. 

S. — Apply as directed. 

If this solution is applied to the right spot and the other directions 
given are carried out very rapid relief will often be obtained. Under 
no circumstance is the patient to be allowed to make these applica- 
tions, for if he does he is almost certain to develop the cocaine habit. 
The physician should make them and not reveal the nature of the 
drug used. Unfortunately, we cannot readily separate those cases 
which are due to nasal disease and those produced by other causes, 
and in consequence this treatment when tried for the first time in a 
given case is purely experimental unless we can discover some hyper- 
esthetic patch in the mucous membrane. 

Benzyl benzoate in 20 per cent, solution given in the dose of 20 to 
30 minims (1.5-2.0) in water three times a day is often advantageous 
and a single larger dose may relieve an attack. (See Part II.) 

The curative treatment of asthma in many cases to a very large 
extent rests upon the use of iodide of potassium, and in the careful 
regulation of the diet and bowels, particularly if the trouble seems to 
be dependent upon indigestion. As the attacks are generally noc- 
turnal, the evening meal should be taken early, be light and easily 
digested, and tea and coffee should be avoided at this time. The 
patient should avoid dusty streets and live in the open air as much as 
possible, and a damp atmosphere is usually preferable to a dry one, 
provided it is not cold. This rule is subject to many variations, and 
each case will be found to be a law unto itself. Each patient must 
try different climates until the proper one is found. Arsenic may be 
used, particularly if the mucous membranes are below par, and a dose 
of bromide of potassium or sodium, 30 grains (2.0) half an hour before 
retiring may be of service. Sometimes the use of mixed phylacogens 
does great good but the Besredka method of testing for hypersensi- 
tiveness should always be used. 

Grindela robusta is largely used as a prophylactic in the dose of 
10 to 30 minims (0.6-2.0) of the fluidextract three times a day. 



694 DISEASES 

Lobelia may also be used in the form of the tincture, 20 minims (1.3) 
three times daily. 

The use of compressed and rarefied air is sometimes of service. 
Inhalations of oxygen are valuable if the cyanosis is extreme. 

In many cases great relief will be given by the use of the bronchitis- 
tent. (See Bronchitis.) 

In those cases in which the presence of nasal polypi or other irrita- 
tions of the air-passages is the exciting cause of the attacks those 
causes must be removed before a cure can be obtained. In other 
instances arsenical wall-papers are the cause of the trouble. In all 
cases of asthma the physician should from time to time examine the 
urine and the heart to determine if the attacks are due to disease of 
the kidneys or to congestion from cardiac failure. 

BED-SORES. 

Bed-sores depend upon disturbances of nutrition resulting from 
pressure exercised in such a manner that the local circulation is inter- 
fered with at a time when the vitality of all the tissues is depressed 
by disease or injury. In most instances the part involved becomes 
chafed by creases in the sheets, by crumbs of food, or by moisture 
from the discharges of the rectum and bladder. Bed-sores can 
usually be avoided by cleanliness unless they are dependent upon 
disease of the trophic nervous system. 

The chief indication is to prevent the trouble by careful nursing and 
cleanliness, which should be supplemented by measures devoted to the 
hardening and improving of the nutrition of the skin covering the parts 
where the sores are apt to appear, as over the buttocks and sacrum. 
To permit of a good supply of blood, the patient should be turned on 
one side or the other every few hours and the skin of the part which 
has been pressed upon rubbed thoroughly with a dry towel to cause a 
healthy circulation and interchange of the nutritive juices. Salt and 
whisky, 2 drams (8.0) to the pint (480.0), may be rubbed over the 
skin, and tincture of gambir or the dilute solution of the sub acetate of 
lead applied to harden it. If this is not used, a mixture of alum and 
spirit of camphor is useful, made by adding 1 ounce (30.0) of pow- 
dered alum to the whites of 4 eggs and mixing this with 2 ounces (60.0) 
of the camphorated spirit. Where the skin is very red and angry- 
looking, but still intact, a solution of nitrate of silver of the strength 
of 20 grains to 1 ounce (1.3 : 30.0) is to be thoroughly painted over the 
spot. All these remedies act by hardening the skin through their 
astringency, or by acting as sedative astringents to the inflamed but 
relaxed capillaries of the part. 

When a bed-sore is developed, measures must be taken for its cure 
and the prevention of its spread. With this object in view the body 
must not rest on the part affected if this can possibly be avoided, and 
in order that the sore may be protected and the pressure equalized, a 



SiLIOUSNESS 695 

large piece of soap-plaster, with its edges deeply incised to make them 
pliable, should be applied after the sore has been thoroughly washed 
out by means of a swab or syringe filled with a 1 : 5000 solution of 
bichloride of mercury, and afterward dusted with iodoform or with 
chloretone and boric acid in equal parts. Sometimes large squares 
of lint thickly covered with zinc ointment are serviceable in lieu of 
the soap-plaster. If the sores spread and burrow through the parts, 
the sinuses should be freely opened and irrigated with peroxide of 
hydrogen, all dead tissues being cut away to avoid sepsis. 

Nitrate of silver in the strength of 20 grains to 1 ounce (1.3 : 30.0) 
may also be used locally as the patient recovers if the ulcers seem 
sluggish. A smooth slip-sheet should always be placed under the 
buttocks. If possible, supportive measures and an increased amount 
of predigested food should be given if the sloughs are large. The 
internal use of iron is particularly valuable in the form of the tincture 
of the chloride in full doses (say 20 minims [1.3]) every four hours. 



BILIOUSNESS. 

This is a term used to designate a state which presents different 
symptoms in different cases, but always includes languor, headache, or 
dizziness, perhaps some yellowing of the skin and conjunctiva, and a 
general sense of atony, mental depression, and discomfort. It 
depends not upon an excessive secretion of bile, but upon some per- 
version of the functions of the liver or the retention of bile in the bile- 
ducts. Further than this, most of the symptoms do not depend 
directly upon the changes in the bile, but upon failure of proper 
digestion in the stomach and intestine, coupled with the development 
of toxic decomposition-products of various kinds. The stomach, 
intestine, liver, pancreas, and their juices all form a complex inter- 
woven chain of function in which if one link breaks the entire chain 
becomes disturbed. The entrance into the stomach of certain food- 
stuffs which are either ill-prepared or improper for gastric digestion 
rapidly causes the development of active fermentation, with the 
formation of lactic and butyric acids, which irritate the gastric 
mucous membrane, and thereby bring about a faulty gastric secretion 
of mucus, which makes still further trouble. 

By the same means the circulation of the stomach is disturbed and 
becomes abnormal, and the intestine, liver, and pancreas receive reflex 
irritation to which they are not normally exposed. Further than this, 
the irritated stomach fails to convert its contents into peptones and 
the general features of chyme, and too early or too late drives out into 
the duodenum a mass of semi-digested and fermenting material 
entirely unfit for intestinal digestion and absorption, thereby disorder- 
ing the functions of these parts still further at a time when they are 
not prepared for the reception of any food. The secretion poured out 



696 DISEASES 

by the different glands varies from the normal; the alkaline juices are 
not able to overcome the normal acid of the gastric juice plus the lactic 
and butyric acids; and finally the reaction of the intestine becomes 
acid instead of alkaline, with resulting irritation and secretion of 
morbid juices and mucus. The trouble when existing in the stomach 
gives rise to headache and discomfort, a bad taste in the mouth, and 
perhaps pain, and is followed by fever, languor, jaundice, and flatu- 
lence when the intestine is affected. 

The cause of these symptoms rests upon the fact that, while gastric 
juice and bile are antiseptic, pancreatic juice mixed with food under- 
goes rapid decomposition, with the development of products of 
decomposition such as skatol and indol and a large number of poison- 
ous alkaloids. Normally, these are not allowed to form, owing to the 
presence of antiseptic bile, which also hurries on the absorption of the 
fats; but if the bile is retained in the ducts, its excretion is impaired 
and its constitution altered by the disorder of the liver which results 
reflexly from the gastric and intestinal irritation. Unfortunately, 
the, complication does not cease at this point, for the liver in health 
has other functions to fulfil, one of the most important of which is 
the arrest and destruction of all poisons of an organic character which 
come to it from the stomach and bowel. Not only are decomposition 
products destroyed by it, but all the vegetable alkaloids are rendered 
innocuous if present in ordinary amounts. 1 The disorder of hepatic 
function therefore permits the entrance into the general circulation of 
these substances, which are very various as regards their powers and 
effects. Thus, Brunton has pointed out that one of these compounds 
closely resembles curare, in that it poisons the peripheral ends of 
the motor nerves, and thereby is at least partly responsible for the 
muscular relaxation and languor often seen in patients suffering 
from so-called "biliousness." Other substances act as do digitalis, 
atropine, muscarine, and picrotoxin, and the number of these various 
compounds is infinite. 2 

It is impossible to give space to a further consideration of these 
poisons, but what has been said shows clearly that " biliousness" only 
expresses a state in which absorption of the bile is not the chief cause 
of the symptoms, but that other poisons are at work. The methods 
of treating biliousness are therefore not to be considered as depending 
upon some regular routine, but upon a study of the case and its 
symptoms. 

Very frequently, after several days of minor discomfort, the disorder 
culminates in a severe sick headache, after which vomiting comes on 
and relief is soon obtained. The manner in which vomiting does good 
is very evident. It compresses the liver and expels inspissated bile 

1 See studies of Schiff, Lautenbach and many others, including Ludwig and Schmidt- 
Mulheim. 

2 See the researches of Schweringer, Zuelzer and Sonnenscheim, Bence Jones, 
Dupre, Rorch and Fassbender, Brieger, Schmiedeberg and Harnach. 



BILIOUSXESS 697 

by the compression exercised by the abdominal walls and diaphragm 
in the effort of vomiting, and thoroughly excites to normal secretion 
the torpid glands of the stomach and intestine. The vomiting or 
lavage also rids the stomach of the fermenting masses and bacteria 
contained in them, and renders the alimentary canal more pure. This 
purity may be increased by giving draughts of plain hot water or hot 
water containing a few grains of bicarbonate of sodium. 

When it becomes evident that an attack is about to begin— that is, 
when constipation, slight drowsiness, or languor after meals shows 
the tendency present— one of two drugs should be used, either podo- 
phyllin if the stools be dark, or calomel if they be light-colored: J 
grain (0.01) of the former to an adult is generally enough, or 1 grain 
(0.06) of calomel divided into six powders, one of which is to be taken 
every fifteen minutes, is a good dose, to be followed in four hours by 
a saline. If the attack is sudden in its onset, no time is allowed for 
these hepatic stimulants, and a saline purge should be used in a good- 
sized dose at once because it sweeps the poisonous matters out of the 
gut before complete absorption can occur, and aids in restoring the 
normal intestinal alkalinity. 

The prevention of "biliousness" depends upon the maintenance of 
a normal, easily digested diet, upon the formation and excretion of 
normal bile, and the prevention of fermentation and decomposition 
in the alimentary tract. 

The term " normal diet" is a very elastic one, and varies with each 
case. While certain forms of food are generally considered good or 
bad, easy of digestion or difficult of assimilation, it nevertheless 
remains a fact that many of the simplest foods are capable of acting 
as poisons in susceptible persons. A large number of persons cannot 
take milk or eggs because their digestion of these substances is faulty, 
and the writer is cognizant of one case where lobster salad can be 
eaten at bedtime without discomfort, while an egg at breakfast will 
cause a severe headache or pain in the belly. Coffee is often the cause 
of biliousness. Fatty foods are to be avoided. Rules as to diet 
must not be "ironclad," but based on observation in each individual 
case. 

By far the best means of maintaining hepatic activity in cases where 
this organ is torpid is horseback exercise, particularly if the exercise 
is taken on a trotting horse, as the jolting of the liver keeps the chain 
of digestive functions active and prevents the secretions from becom- 
ing clogged. Along with this exercise massage of the hypochondrium 
and belly-walls is useful, and the movements of stooping over, bending 
from side to side, and bending backward with the feet close together, 
are of value. 

The use of the pure (strong) nitrohydrochloric acid in these cases in 
the dose of 5 minims (0.3) three times a day in half a tumblerful of 
water is invaluable, and the fluidextract of stillingia in the dose of 20 
minims (1.3) is of service, as is also the solid extract of euonymus in 



698 DISEASES 

the dose of 3 grains (0.2). Five-grain (0.3) doses of extract of chirata 
in pill are also useful in hepatic atony of a mild type. 



^ — Extracti chiratse 


gr. xl (2.6) 


Podophyllini 


gr. iv (0.25) 


Euonymini 


gr. viij (0.5) 


Leptandrini 


gr. viij (0.5) 


Creosoti 


gr. x (0.6).— M 


Fiant pilulse, No. xx. 




S. — One pill every night. 





The knowledge of the action of many of the poisonous materials 
formed in the alimentary canal renders it possible for us to relieve the 
patient by other means than those which may be generally resorted to 
when the attack is present. Thus if the pulse be slow and full, the 
arterial tension high, and there is throbbing in the head, with frontal 
headache, the toxine representing digitalis may be antidoted by the 
use of aconite. If nervousness and irritation are present, the bromides 
and chloral may be used. 

The use of caffeine in the headaches of biliousness nearly always 
makes them worse, particularly if the headache is due to over- 
indulgence in coffee. (See Headache.) 

If the face is flushed, a mustard plaster or dry cup to the nape of the 
neck may be used, and a hot foot-bath is often of service. 

In cases where the bilious attacks are associated with catarrh of 
the stomach, intestines, or bile-ducts, chloride of ammonium, in 
5-grain (0.3) doses, three times a day, is very useful, as is also the 
protiodide of mercury, when triturated with sugar of milk, in the dose 
of -gV *° to grain (0.001-0.0015) three times a day. Frequently the 
use of salol or aspirin in 10-grain (0.6) doses, three times a day, does 
much good in these cases, acting as an intestinal antiseptic. (See 
Salol.) 

BLEPHARITIS. 

Blepharitis is divided clinically into an ulcerative and a non-ulcera- 
tive variety. The indication of prime importance in the treatment 
of this affection is the removal of the scabs and crusts before the 
application of the local remedies. This may be accomplished by 
the use of alkaline solutions, bicarbonate or biborate of sodium (8 
grains to the ounce [0.5 : 30.0]), or daily gently scrubbing of the lid 
margins with the lather of a good neutral soap. The salves that have 
met with the greatest success are Pagenstecher's ointment yellow 
oxide of mercury, 1 grain (0.06), vaseline, 1 dram (4.0), dilute citrine 
ointment, aristol ointment, boric acid ointment, or a 3 per cent, milk- 
of -sulphur ointment, to which resorcinol may be added. The latter 
application is useful in the squamous variety alone. Blepharitis due 
to the presence of the Morax-Axenfeld bacillus should be treated by 
application of a 1 per cent, solution of sulphate of zinc. In the ulcer- 
ated form, if the crusts are tenacious, these, as well as the stunted 
cilia, must be removed with forceps, and yellow-oxide-of -mercury 



BOILS 699 

ointment, or some similar application, applied. Excellent results 
follow touching the crater-like abscesses in the edges of the lid with 
nitrate of silver. If there is an accompanying conjunctivitis, a boric- 
acid solution is suitable, while in any circumstances obstruction of 
the lacrimal duct— a frequent accompaniment of the diseases— must 
be removed and the nasal passages explored for any chronic inflam- 
matory condition. The relation between this disease and refractive 
errors demands the correction of the latter before a hope for cure 
may be entertained. 

BOILS. 

Boils are dependent upon an infection of the sweat glands, or, more 
rarely, on some local trouble situated in the skin, as in the persons 
of oil- or paraffin- workers. 

When boils are persistent and recurrent some cause which decreases 
vital resistance should be sought for. 

The constitutional treatment rests upon the use of fresh air, cod- 
liver oil, iron, arsenic, phosphate of sodium, and, if any boils are 
present, the use of sulphurated calcium in the dose of y^ grain (0.006) 
every five hours. The sulphurate of calcium hastens the matura- 
tion of boils and prevents the formation of new ones, but is useless, 
according to its original user, Dr. Ringer, in the boils which appear 
during the course of some cases of diabetes. 

The local treatment of boils may be divided into the abortive and 
curative methods. The abortive method consists in painting around 
the inflamed spot, when the trouble first begins, with solution of gun- 
cotton (collodion), and renewing the coat hour after hour until a 
heavy contractile covering is formed. The center of the swelling 
must not be covered by collodion. If pus forms under this, it may be 
absorbed; but if this does not occur, then the boil must be opened 
under antiseptic precautions and properly dressed. A strong solution 
of nitrate of silver is also very useful at the beginning of the formation 
of a boil if painted over the part in the strength of 20 grains (1.3) to 
(1.3) to the ounce (30.0). The other local applications consist in the 
use of the extract of opium or belladonna over the part to relieve pain 
and decrease the inflammation. Poultices may also be used to relieve 
the sensation of tenseness and mature the boil, and should contain 
sweet oil and laudanum. 

Ringer recommends the application of alcohol and camphor over 
the skin in the early stages. After the skin is wiped dry it is to be 
smeared with camphorated oil. Stelwagon uses the following: 

3— Ichthyolis . 3j (4.0) 

Emplastri plumbi 3ij (8.0) 

Emplastri resinae (U. S. P. 1890) 3ij (8.0).— M. 

S. — Apply to the part. 

He also approves of the injection of a few minims of a 5 per cent, 
solution of phenol into the apex of the boil if its formation is assured. 



700 DISEASES 

A very useful plan after the boil has formed is to wrap a little 
absorbent cotton around a sharp stick, dip it in phenol and bore it into 
the center of the boil, taking care not to bore beyond the base of the 
pus cavity. The parts are then washed with peroxide of hydrogen and 
dressed with a 10 per cent, ointment of salicylic acid. If there is a 
large slough that does not come away, the part may be dressed with a 
1 per cent, solution of sodium citrate placed on lint or gauze. 

When boils occur in the external ear, the canal should be frequently 
irrigated with hot water, and if the boil is mature it is to be incised. 
A useful pain-relieving dressing for the boil is as follows: 

1$ — Iodoformi gr. iv (0.25) 

Mentholis gr. ij (0.12) 

Petrolati 3j (4.0).— M. 

S. — Smear on cotton plugs and insert in the ear twice or thrice a day. 

The use of staphylococcic vaccine is not to be forgotten. (See 
Vaccine-therapy.) 

BREAST (INFLAMED). 

Lactation should at once cease and the milk be removed by the aid 
of massage and the breast-pump. A bandage exercising pressure is 
now applied and an ice-bag placed over it. This is only useful in 
those cases in which the glands are the part affected. When the con- 
nective tissue is involved, lead-water and laudanum should be applied 
and saline purgatives used. Belladonna ointment may be smeared 
over the breast with advantage in both forms to check secretion and 
allay inflammation. As soon as pus has formed it should be set free 
by an incision in the line of the ducts. If it be deeply situated, the 
breast should be incised close to the chest and the pockets opened by a 
grooved director or dressing-forceps and packed with gauze. 

In the early stages of the inflammation, if the circulation is bound- 
ing, it should be thoroughly impressed by aconite or veratrum viride 
and belladonna. 

BRONCHITIS (ACUTE AND CHRONIC). 

In the early stages of bronchitis there is always present a very dis- 
tinct hyperemia, followed by a true inflammation of the mucous 
membrane lining the bronchial tubes. When these changes are con- 
fined to the larger bronchi the term "bronchitis" is employed, but 
when the minute bronchioles are invaded the disease is known as 
"capillary bronchitis." In many cases the physician only sees the 
patient when the second stage of the disease is present, but if the 
individual presents himself promptly, the following history and 
physical signs will indicate the treatment to be employed: After 
exposure, more or less severe, to wet, dampness, or dry cold, a sensa- 
tion of oppression comes on, associated with a feeling of "tightness 
across the chest" or a sensation as if a bolus of food was under the 
sternum. Aching and pain may be traced over the lines of the 



BRONCHITIS 701 

bronchial tubes, while the dry, hacking cough increases the discom- 
fort and seems to strain the tubes until each one can be outlined on 
the chest-wall by the patient. The cough, when it occurs, is virtually 
unproductive, and often causes pain in the larynx and throat. On 
making examination by auscultation there will be found over the 
posterior aspect of the chest, between the shoulder-blades, sounds 
of bronchial breathing, which are rougher than normal, and due to 
the air passing over an inflamed, swollen, and roughened mucous 
membrane. This bronchial roughening may be sufficient to cause 
a harsh inspiratory sound over the entire chest, and the expiratory 
sounds may be heard a little louder than usual. No other changes 
from the normal can be noted, but isolated spots of discomfort may 
be pointed out by the patient, where aches, "catches," or "kinks" 
seem to be present in a previously normal tube. Percussion, palpa- 
tion, and inspection show nothing more of note. Some fever may be 
present. 

The patient should receive a hot foot-bath, take a glass of hot 
lemonade with a little whisky in it, and go to bed at once, in order that, 
by inducing a profuse perspiration, he may relieve the bronchial 
congestion. Often a dose of Dover's powder is useful in hearty adults 
to aid in causing perspiration. In children the chest should be well 
rubbed with camphor liniment and a little tincture of aconite be given 
in water with sweet spirit of nitre every hour, as follows : 

1$ — Tincturae aconiti Tfl.xxiv (1.5) 

Spiritus setheris nitrosi f3ij (8.0) 

Aquae destillatse q. s. ad f gj (30.0). — M. 

S. — A half-teaspoonful (2.0) to a child or a dessertspoonful (8.0) to an adult in 
water every hour. 

In many adults 5 to 10 grains (0.3-0.6) of Dover's powder, with a 
hot drink, are better. 

If the attack is not aborted while the first stage is still present, 
before secretion is established, resort should be had to ipecac and to 
citrate or acetate of potassium, which act as sedatives to the inflamed 
mucous membranes and aid in the formation of secretion, moistening 
the inflamed surfaces and thereby overcoming the dryness and irrita- 
tion. These potassium salts also act as febrifuges, and should be 
used in full doses, as much as 40 grains to 1 dram (2.6-4.0) a day, in 
addition to the aconite already recommended. The following pre- 
scriptions illustrate their employment: 

I$— Syrupi ipecacuanha} f3J vel f5iij (4.0-12.0) 

Potassii citratis 3iv (16.0) 

Aquse destillatse q. s. ad f§vj (180.0). — M. 

S. — Dessertspoonful (8.0) every four hours for a child of five years. 

Or, 

1^ — Syrupi ipecacuanhas fgj (30.0) 

Succi limonis fgj (30.0) 

Potassii bicarbonatis 5iv (16.0) 

Spiritus setheris nitrosi f 5j (30.0) 

Aquse destillatse q. s. ad f 5vj (180.0).— M. 

S. — Dessertspoonful (8.0) every four hours for an adult. This mixture should not 
be corked for some time after it is made. 



702 



DISEASES 



For a child this prescription should be reduced just one-half in each 
part, with the exception of the water. 

In some cases, particularly if the patient be a child, large doses of 
the citrate, or other salt, of potassium exert a depressing influence and 
have to be decreased. 

Count erirritation may be applied to the chest in the shape of a 
mustard- or spice-plaster. If the soreness of the bronchial tubes is not 
relieved by this means, inhalations of steam arising from boiling water 
may be practised, either through a cone, one end of which covers the 
top of a pitcher and the other end of which covers the mouth and nose 




Fig. 126. — Bronchitis-tent put up by aid of two sheets pinned together and four 
broomsticks lashed to corners of bed. The steam arises from an Arnold steam sterilizer 
to which has been attached a tube. When in operation the side flap of the tent is 
dropped. 



of the patient, or by covering the head and pitcher with a towel. The 
usefulness of this method may be much increased by the addition of 1 
tablespoonf ul of compound tincture of benzoin to each pint of water. 
In young children, particularly in the first stage of bronchitis and in 
the later stages, the use of the so-called "bronchitis-tent" is of great 
value. It consists of a canopy raised over the bed a sufficient distance 
to allow of the circulation of plenty of air. Through one side of this 
canopy passes a tube leading from an Arnold steam sterilizer, under 
which is an alcohol lamp to keep the temperature of the water suf- 
ficiently high (Figs. 126 and 127). By this means the air breathed by 



BRONCHITIS 



'03 



the patient is so saturated with moisture that the mucous membrane 
lining the air-passages is soothed and quieted. In order that the full 
benefit of this measure be understood, it must be remembered that a 
mucous membrane in the early stages of inflammation is always dry 
and red, lacking its normal moisture, and that the upper air-passages 
fail to catch upon their surfaces, by reason of their dryness, particles 
of dust, and do not moisten the air before it reaches the lungs. Again, 
it will be remembered that the bronchial mucous membrane is 
covered with ciliated epithelium, which, by the constant, upward, 
wavy motion of its cilia, urges out of the lungs all impurities. Dry- 
ness of the surface at once stops this ciliated movement, with unfavor- 
able results. The employment of the "bronchitis-tent" is equally 
useful in adults, but less readily employed, owing to the size of the 
bed. 




Fig. 127. — Arnold steam sterilizer, showing self-feeding reservoir and small volume 

of water to be heated. 



Having considered the treatment of the first stage of bronchitis, We 
pass to that of the second. The condition of the mucous membranes 
is now quite different from that which has just been spoken of. In 
the place of an absolute lack of secretion a profusion of cast-off 
epithelial cells, a large amount of mucus, and more or less liquid 
have been poured out upon the walls of the bronchial tubes, forming 
obstructions everywhere to the ready passage of air. The secretion is 
apt to be more or less viscid and ropy, and, when it is coughed up 
after considerable effort, appears in lumps, particularly in the morn- 
ing. This state is one in which the excitement of inflammation is 
followed by local depression and an effort on the part of the tissues to 
rid themselves of the congestion and of the excess of mucus and epi- 
thelial cells. The physical signs on listening to the chest are now found 
to consist in a large number of loose rales, which are distinctly wet 



704 DISEASES 

and moist. Later they become markedly liquid and bubbling, and 
so cause gurgling on inspiration and expiration. Sometimes they are 
musical or squeaking. Generally the latter signs do not come on 
until the case is far advanced, and, if a cure is soon to be reached, they 
last only a few days or hours, as the mucus is so loose as to be easily 
coughed up and the tubes readily cleared. 

The object of the physician is to use remedies which will stimulate 
the bronchial tubes and increase the volume of liquid poured out. 
For this purpose the bonchitis-tent may of course be employed, but 
the drugs to be used internally are the chloride of ammonium and the 
pitches and turpentines, such as terebene, or terpine hydrate. 

In the majority of instances an ammonium mixture will be the best 
and most serviceable prescription, in one of the following forms : 

1$ — Ammonii chloridi 3i.i (8.0) 

Fluidextracti glycyrrhizae f 5ij (8.0) 

Aquae destillatae q. s. ad fgiij (90.0). — M. 

S. — Teaspoonful (4.0) to dessertspoonful (8.0) every four hours. 

Or, 

ly — -Ammonii chloridi 3ij (8.0) 

Misturae glycyrrhizae compositae f giij (90.0). — -M. 

S. — -The same dose. 

The advantage of the latter prescription is the presence of antimony 
in the compound liquorice mixture, which tends to increase secretion, 
but is contraindicated if debility exists. 

If the cough is troublesome, a little morphine or heroin may be 
added, or the following be used particularly if any signs of cardiac 
failure appear: 

1$ — Ammonii chloridi 3J (4.0) 

Ammonii carbonatis 3j (4.0) 

Ammonii bromidi 3 J (4.0) 

Fluidextracti glycyrrhizae . . . . . . . f3iv(16.0) 

Aquae destillatae f$vj (180.0).— M. 

S.— Dessertspoonful (8.0) every four hours. 

In this prescription the first constituent acts particularly on the air- 
passages, the second stimulates the heart and respiration, and the 
third allays the cough, while the liquorice masks the salty taste of the 
ammonium. Still another recipe is : 

I^— Codeinae sulphatis gr. ij vel iv (0.12(0.25) 

Ammonii chloridi 3J (4.0) 

Fluidextracti glycyrrhizae f5J (30.0) 

Aquae destillatae q. s. ad fgij (60.0).— M. 

S. — Teaspoonful (4.0) every two hours in water. 

An oronasal respirator, with the sponge saturated with equal parts 
of terebene, iodide of ethyl, and chloroform, may be worn in order to 
allay cough and loosen the mucus. Sometimes the use of a nebulizer, 
as shown on page 610, is very useful, or Yeo's inhaler may be used. 
(See Creosote, Part II., and Inhalations, Part III.) 



BRONCHITIS 705 

If the administration of the chloride of ammonium does not aid in 
the expulsion and liquefaction of the secretion and rid the lungs 
rapidly of the mucus, the use of terebene in 5- or 10-minim (0.3-0.6) 
capsules may be resorted to with success. If capsules cannot be sup- 
plied, terebene may be made into an emulsion with acacia or trag- 
acanth and given in this way. Sometimes terebene will irritate the 
kidneys and produce a sense of weight across the loins; if this occurs, 
its use should be stopped. In other cases it will disorder the stomach, 
or cause diarrhea. These effects are not, however, commonly seen. 
Terpine hydrate in 10-grain (0.6) doses may be used three times a 
day, or terpinol in the dose of 8 to 10 grains (0.5-0.6) in capsules or 
pills. 

An excellent combination is the elixir of terpine hydrate with 
heroin, which may be given in the dose of a dessertspoonful (8.0) every 
four hours in a little water. Certain of the volatile oils and resins are 
also of value at this time, notably the oleoresin of cubebs and copaiba, 
which, however, possess the disadvantage of disordering the stomach. 
The oil of eucalyptus is also of great value, and may be given in cap- 
sule or emulsion in the dose of from 1 to 5 minims (0.06-0.3) every five 
hours. The oil of sandalwood in the dose of 5 to 10 minims (0.30-0.6) 
is very valuable, and is not so apt to disorder the stomach, bowels, and 
kidneys as are some of the other remedies named. 

While the proper use of these remedies usually brings about the 
results desired, in some cases a stage of profuse secretion comes on 
which in its treatment is identical with that seen in chronic bronchitis, 
and chronic "winter cough" with emphysema, so these diseases will 
therefore be considered together. 

In old persons suffering from dilated bronchial tubes, from emphy- 
sema, and from chronic bronchitis there is constantly poured into the 
air-passages so free a secretion that persistent coughing is necessary 
to rid the lung of enough of the mucus and liquid to enable them to 
breathe. Any excess of this exudation drowns him in his own secre- 
tions, and the constant obstruction to the ready flow of air and blood 
in the lung soon produces dilatation and weakness of the right side of 
the heart. 

The same condition in a more acute form sometimes asserts itself 
in young children and in adults. In children it sometimes comes 
on so suddenly as to be known as "acute suffocative catarrh," while 
in older persons it appears with sufficient severity to make the con- 
dition of the patient most serious. Of the treatment of the latter 
state the writer will speak at once. 

The objects desired are to rid the lung of the liquid secretions, to 
prevent the outpouring of more exudate, and to support the patient 
until the crisis is past. Digitalis should be administered to support 
the heart, and strychnine be employed in full dose to stimulate the 
respiratory center and excite the nervous system, which is generally 
depressed by the increasing carbonic acid in the blood. For the same 
45 



706 DISEASES 

purposes caffeine or strong coffee may be used. Oxygen may be in- 
haled, and to check the profuse secretion atropine should be used by 
the mouth or hypodermically. When cyanosis is marked and the 
patient is a child, it may be alternately dipped in a tube of hot and 
cold water to cause reaction and stimulate the dormant nerve centers 
to greater activity, and so by reviving the patient sufficiently, respira- 
tion is maintained until voluntary efforts are made by the patient. 
Sometimes letting the patient hang his head over the side of the bed 
when he coughs may aid in the expulsion of the liquid. 

The treatment of the more moderate condition of excessive secre- 
tion in the bronchitis of old persons, which is more slow in its progress, 
but which may end as fatally as like attacks in the young, is some- 
what similar to that just given. Injurious results are often produced 
by the physician failing to recognize that the secretion is sufficiently 
fluid, and that ammonium chloride and such expectorants are not only 
useless, but distinctly harmful because they increase the quantity of 
these liquids. Under these circumstances the application of several 
dry cups over the bases of the lungs posteriorly often gives a great 
deal of relief; or if cups cannot be obtained, then active counterirrita- 
tion by means of a mustard-plaster or turpentine stupe is advisable. 
The cups are, however, the remedy of choice. Atropine, which 
checks secretion, stimulates the respiratory center, and is for this 
reason a useful remedy. Strychnine is, however, the best of remedies 
to help the patient get rid of the sputum. It should be given in the 
dose of yV grain (0.006), or more, three times a day. When the 
condition is pressing atropine and strychnine should be used hypo- 
dermically. 

The use of remedies designed to allay the cough in these cases is 
absolutely unjustifiable, as it results in retention of the profuse secre- 
tion. The question as to whether the cough is excessive or not must 
depend on the ability of the patient to rid himself of the secretions 
in the bronchial tubes. 

BURNS AND SCALDS. 

The treatment of burns and scalds is both internal and external, 
the first being devoted to the relief of pain, and the treatment of 
shock; and the second to the care of the injured surfaces. Immedi- 
ately upon being called to a severe case of burn it is the duty of the 
physician to determine how badly shocked the patient is, what the 
condition of the pulse may be, and whether or not the lungs and air- 
passages are involved. After these mental notes he should give a 
hypodermic injection of } to J grain (0.015-0.03) of morphine and T io 
of atropine (0.0006), and then roll the entire body in a large blanket to 
maintain the bodily heat, while the sufferer is being transferred to the 
hospital or the house to which he belongs. 

In some cases the shock is so great that the pulse flags at once, the 
temperature falls, and collapse ensues. Stimulants hypodermically, 



BURNS AND SCALDS 707 

external heat, and drinks of hot water and whisky are indicated, fol- 
lowed by 2V grain (0.003) of strychnine and \ grain (0.03) of digitalone 
if the circulation does not respond to the less powerful stimulants. 
Adrenalin chloride, 1 dram (4.0) of a 1 : 1000 solution may be given 
intravenously in a pint of normal saline solution in severe cases, or 
normal saline by hypodermoclysis to the amount of \ to 1 pint (250- 
500). A very useful treatment under these circumstances is to 
immerse the patient in a bath of normal saline warm enough to main- 
tain the bodily temperature. Often while in this bath the burned 
cuticle is easily removed with but little pain, and the protection from 
the air decreases dermal irritation. The patient should be allowed to 
remain in the bath as long as shock lasts. The treatment of this state 
is far more important than the care of the burns. The removal of 
clothing and the application of dressings must wait until the patient 
has rallied well. (See article on Shock.) When the toxemia is 
severe, particularly in a child, transfusion of blood may save life. 

In the local treatment of burns, an excellent treatment is the 
application of a solution of picric acid on lint or wet picric acid 
gauze. Oily dressings are dirty surgery. The picric acid solution is 
of the strength of 1 per cent, in water, and after the lint or gauze is 
applied the parts are covered with a dressing of absorbent cotton and 
a bandage. The gauze used should be in comparatively small sections 
since it is easier to remove in this form than in one large piece. If 
blisters or blebs are found, these should be punctured but not removed. 
This dressing in moderate burns is allowed to remain in place until 
healing is complete. In severe burns or scalds it is changed on the 
second or third day, the first dressing being softened before removal 
by applying some of the picric acid solution. This treatment relieves 
pain, prevents suppuration, and results in a smooth cicatrix. If 
suppuration occurs, the parts are to be washed free of picric acid by 
means of normal salt solution, followed by hydrogen peroxide solution, 
then, after drying with compresses of cotton, dressed again with 
picric acid. Fingers and toes are to be separated by wet pieces of the 
gauze or lint. Indolent healing is best treated by resin cerate. 

Still another very efficacious application to burns is that of the 
late Professor Rice. It is better than Carron oil or many of the 
preparations ordinarily used. It is as follows: 

1^— White gelatin Sviiss (225.0) 

Glycerin fgj (30.0) 

Phenol f 5j (4.0) 

Water f5xvj (480.0) 

Soak the gelatin in the water until it is soft; then heat it on a water-bath until 
it is melted. Add the glycerin and continue heating until a firm, glossy skin begins 
to form on the surface of the mixture, in the intervals of stirring. Now add the 
phenol and mix intimately. 

This mixture may be kept ready prepared, and is best preserved in 
well-closed glass or porcelain jars. When wanted for use, it is heated 
on a water-bath until just melted, and applied with a soft flat brush 
over the burned part, where it forms a strong flexible skin. 



708 DISEASES 

During the great war the following formula has been largely used 
as a spray from a coarse oil atomizer, the mixture being kept in 
a fluid state by heating above 122° F. In a slightly different form 
it has been called "ambrine." 

Per cent. 

Betanaphthol 0.25 

Oil of Eucalyptus 2.0 

Olive oil 5.0 

Hard paraffin • 25.0 

Soft paraffin 67.75 

If a spray cannot be had it may be applied with a sterile brush. 

It has become increasingly apparent, however, that such mixtures 
are no better than plain paraffin, and that it is essential after removing 
dirt, opening blebs and clipping off free skin to dry the surface by an 
electric dryer such as is used by barbers or by fanning it, and then 
paint it with liquid paraffin over which is laid a thin layer of coarse 
gauze the threads of which should be preferably already impregnated 
with paraffin, and over this in turn is painted the melted paraffin. 
The solid paraffin should melt at 50° C, (122° F.) and should be pliable 
at 28° C. (82.4° F.), and several layers of dressing extending over the 
adjacent healthy skin should be applied. This plan is clean, efficient 
and cheap. The dressing should be changed in twenty-four hours, 
and the wound cleaned not by the aid of liquids but by patting it with 
dry gauze. (See Antiseptics p. 546.) 

Whenever the urine is high colored and cloudy the citrate of potas- 
sium should be freely given, 20 grains (1.3) in water three times a day, 
combined with 30 minims (2.0) of sweet spirit of nitre. 

CHANCROID. 

The chancroid is a contagious ulcer which has no definite period 
of incubation, is distinctly inflammatory in type, and is usually mul- 
tiple. It is further distinguished from the primary sore of syphilis 
by the fact that it is auto-inoculable, is not followed by secondary 
eruptions, and, if it involves the lymphatics at all, produces an 
acute inflammatory swelling which frequently attains a considerable 
size, and suppurates. A specific bacillus can be recovered from its 
discharge. 

Chancroid, being purely a local affection, would seem to require 
nothing more than local treatment; this is true of the uncomplicated 
sore, but where phagedena or serpiginous ulceration sets in, the 
question of constitutional treatment is of importance. 

The treatment of uncomplicated chancroid in its early stage is as 
simple as it is efficient. One thorough cauterization converts the sore 
into a healthy ulcer, the cicatrization of which is quickly and surely 
accomplished. 

As the most efficient means of thoroughly destroying chancroidal 



CHANCROID 709 

ulcerations the actual cautery is chiefly commended. This is, how- 
ever, objectionable to patients. Nitric acid will be found equally 
serviceable; it may be applied by means of a glass rod or a cotton 
applicator. The pain of these applications may be greatly lessened 
by the previous employment of a 20 per cent, solution of cocaine. 
When the surface involved is large, the patient should be etherized. 
The cardinal point in the cauterization of chancroids is to reach 
and destroy all the diseased area. Each pocket and sinus must be 
thoroughly acted upon, otherwise it remains as a focus for reinfec- 
tion. For one or two days after cauterization the parts should be 
dressed with gauze kept wet with a mixture of dilute lead-water and 
alcohol equal parts. Thereafter dry dusting-powder may be used. 

There has been a tendency of late years to substitute for this treat- 
ment one less radical, more acceptable to the patient, and in many 
cases almost equally satisfactory in results. Many of the chancroids 
as found in persons of robust health show little tendency to spread, 
and are amenable to mild treatment. It must be remembered, how- 
ever, that as long as the smallest portion of such an ulcer remains 
unhealed, it may at any time take on all the features of a virulent 
ulceration. Moreover, the patient is constantly exposed to the risks 
of a chancroidal bubo— a complication so troublesome that the 
possibility of its development constitutes the strongest argument 
against palliative in distinction from radical treatment. 

Where the ulceration is entirely superficial, constituting the erosive 
form of chancroid, iodoform, dusted over the surface of the carefully 
cleansed granulations, offers the best form of palliative treatment. 
The dusting-powder should be preceded by careful spraying with per- 
oxide of hydrogen 1 : 4, followed by a spray of mercury bichloride 
1 : 4000. The objection to iodoform lies in its odor. To overcome 
this, the powder should be dusted only upon the sore. The odor can 
be disguised to some extent by thoroughly mixing with the iodoform a 
small quantity of one of the essential oils, such as oil of peppermint or 
attar of roses, using not more than 5 minims (0.3) to 1 dram (4.0) 
of the powder. There is no dusting-powder which can entirely take 
the place of iodoform, yet, w T hen the objections to the use of the latter 
are insuperable, thymol iodide or iodol may be substituted, or a mix- 
ture of 1 dram (4.0) of zinc oxide and 3 drams (12.0) of subnitrate 
of bismuth, or equal parts of calomel and bismuth. If the dusting- 
powder be allowed to form a crust beneath which the discharge col- 
lects under some tension, the development of bubo will be distinctly 
favored. It is, therefore, needful when dusting-powders are used that 
the dressing should be repeated several times a day, the lesion being 
first cleansed, then dried by means of absorbent cotton, and finally 
dusted with the powder of choice. Gauze dressing is then secured in 
place by bandages, straps, or, when this is applicable, by pulling the 
foreskin forward. 

Wet applications frequently changed, because of the greater clean- 



710 DISEASES 

liness and better drainage which they insure, are less likely to be fol- 
lowed by complications than are dusting-powders. In the small not 
markedly inflammatory or rapidly progressing lesions it suffices to 
supply the patient with a bottle of antiseptic solution— dilute lead- 
water answers well— and an adequate quantity of cotton or gauze. 
At each act of urination he changes his dressing, retaining it in place 
in the simplest practicable way, spraying the lesion night and morning 
with dilute peroxide solution. When, however, the sore is attacked by 
a high grade of inflammation, prolonged immersion of the part in- 
volved or of the whole body in hot water is indicated, followed by the 
application of dressings kept constantly wet with dilute lead-water 
and alcohol. 

Where the chancroid assumes the phagedenic type, extending with 
great rapidity and causing extensive sloughing and destruction of 
tissue, free cauterization, either with the hot iron or by means of nitric 
acid, should be instituted immediately, every portion of the ulcerating 
surface being thoroughly destroyed. This should be followed by pro- 
longed hot sitz-baths or general warm baths, the patient remaining in 
the water for days at a time if necessary, and, if practicable, eating 
and sleeping with the body still immersed, the body and limbs being 
covered with a salve to prevent maceration of the skin. If this is 
not possible, baths of from two to four hours' duration should be 
given two or three times daily. In addition, the patient may be 
given full doses of opium, and should receive a tonic and supporting 
treatment. 

Should the chancroid assume the serpiginous type, slowly extending 
in spite of treatment, until in the course of months or years large areas 
are destroyed by the process, the warm bath, continued night and day 
for weeks at a time, together with thorough cauterization of the entire 
diseased surface with the hot iron, represents the most satisfactory 
method of treatment. In phagedenic and serpiginous cases the 
reactions for syphilis (Wassermann, Noguchi) should be taken, and 
if they be positive, arsphenamine should be given. 

The chancroidal bubo is best avoided by prompt and thorough cau- 
terization of the sore, or by frequent thorough cleansing and the 
avoidance of retained discharge; when it occurs, however, it should be 
first treated by rest, pressure, and counterirritation, since it may be a 
simple inflammatory adenitis, and with care may not go on to suppura- 
tion. The patient should be put to bed, and a compress should be 
applied, kept wet with dilute lead-water and alcohol, and held in place 
by a spica bandage of the groin; or this may be substituted by com- 
presses soaked in ichthyol solution (1 : 40), over which is laid a hot- 
water bag. At the first sign of suppuration the bubo should be 
punctured by a tenotome, evacuated, washed out with a bichloride 
solution (1 : 1000), and dressed antiseptically. If there be a reaccu- 
mulation of pus, the puncture and washing should be repeated. If 
inflammatory symptoms still persist, the diseased gland should be 



CHOLERA, ASIATIC 711 

thoroughly removed by dissection or the curette through a free open- 
ing, the resulting wound being drained by gauze and sutured. If the 
bubo take on phagedenic action, it should be treated as the phagedenic 
chancroid. 

CHLOROSIS. 

(See Anemia.) 

CHOLERA, ASIATIC. 

The treatment of this exceedingly dangerous disease is prophylactic, 
curative, and convalescent. 

The first measure consist of strict quarantine, both public and 
private, the avoidance of all water for culinary purposes which has not 
been boiled at least an hour and cooled in a place devoid of germs, 
the use of no food which may be contaminated, and the employment 
of those foods which, while preserving the normal bodily health, in 
no way predispose to intestinal disturbances, as do some of the 
fruits, as melons and grapes. If these precautions are observed, little 
remains to be done. 

"Accumulating evidence is to the effect that the internal use of 
kaolin (Chinese clay) is the best form of internal medication. Kaolin 
is insoluble in water and has to be given in the form of a bolus or by 
getting the patient to partake freely of a half and half mixture of 
kaolin and water, there being no limit to the dose as kaolin is not 
absorbed. Even if it is vomited the attempt to take it should be per- 
sisted in, all food being withheld for twenty-four hours. Walker states 
that it should also be given by rectal injection as soon as the bowel 
will tolerate it. The treatment is said to cause marked improvement 
in twelve to twenty-four hours and the change for the better is shown 
by the arrest of vomiting, a decrease in the stools in a rapid diminu- 
tion of toxemia, and a return of renal secretion and consciousness in 
those far enough advanced to have these symptoms. As kaolin has 
no bactericidal effect its action is probably due to its absorption of 
the toxins and its mechanically surrounding the vibrios. It also coats 
the entire lining of the bowel so as to arrest absorption of toxins. It 
has been proved that if cholera toxins are mixed with a kaolin suspen- 
sion they lose their toxic properties. 

The use of a remedy originally proposed by Dr. R. G. Curtin has 
been proved to be eminently rational. This agent is sulphuric acid. 
This drug not only is acid, and so deleterious to the bacillus, but, 
in addition, is astringent, and is probably eliminated as a sulphate by 
the lower bowel. As is well known, ordinary cholera morbus yields 
readily to its influence. 

Camphor, seems to be universally regarded as a most useful drug, 
tending at once to check diarrhea and relieve the pain and cramps 



.712 DISEASES 

from the beginning to the end of the attack. Whether camphor 
exercises any germicidal effect on the cholera bacillus we do not know. 
Certain it is that volatile oils all possess distinct antiseptic powers. 
Aside from any such influence, camphor is useful as a general systemic 
stimulant, and has been proved by wide clinical observation to have 
a very extraordinary power in the control of all forms of serous diar- 
rhea, particularly that of true cholera. The spirit of camphor has 
proved most effective in cholera epidemics. Frequently the use of 
camphor so controlled the diarrhea and stimulated the torpid kidneys 
that anuria was relieved in twenty-four hours. Under these conditions 
camphor wine has been found very useful; it is made by adding 75 
grains of finely powdered camphor to a quart bottle of strong red wine, 
to which are also added gum arabic and alcohol. The camphor is first 
dissolved in the alcohol, and then thoroughly mixed with the wine. 
The dose of this mixture is a teaspoonful, in peppermint-tea, every 
hour to a child of six years; for an older child a dessertspoonful, and 
for an adult a wineglassful. Those who first used this mixture were 
wiser than they thought, for the studies of Pick have shown that both 
red and white wine are distinctly inhibitory to the growth of the micro- 
organism of cholera, probably because of the tannic or other acid 
which they contain, as well as the alcohol. 

The experience of English physicians in India indicates that per- 
manganate of potassium, given in keratin-coated pills so that it will 
not be decomposed in the stomach, in the dose of as much as 1 dram 
(4.0) in six hours, is probably even more useful than camphor. 

A remedy, the use of which is based on very rational grounds, is 
salol, and probably the newer drug, aspirin, which, theoretically, is 
much better than the former, because it is less poisonous. According 
to the interesting studies of Lowenthal, salol seem to be peculiarly 
antagonistic to the bacillus of cholera. This investigator added to a 
50-gram alkaline solution of pancreatic juice 10 grams of salol, and to 
this mixture 3 cc of a virulent bouillon culture of the bacillus. Ex- 
aminations in forty-eight hours to a week showed this to be absolutely 
sterile. It was further proved that the salol was inactive until broken 
up into its component parts— phenol and salicylic acid. Hueppe also 
asserts that the use of salol prevents the development of anuria. 

Vomiting, purging, toxemia, cramps in the extremities, and, as the 
result of these, exhaustion, collapse, and the advent of the algid stage 
are to be combatted by intra-abdominal or intravenous injection of 
saline solution (which see) ; or, if this is not possible, hypodermoclysis 
and the employment of a hot- water bed; or, hot bottles and bricks. 
It has been found that the strength of the saline solution given by the 
vein should be greater than usual, namely, about 1 per cent., and from 
three to five pints should be used whenever the blood-pressure in a 
European is as low as 80 mm. of Hg., or the specific gravity of his 
blood is more than 1063; 1056 being about normal. The flow should 



CHOLERA IXFAXTUM 713 

be at the rate of about 1 ounce (30.0) a minute. After the intravenous 
injection has rallied the patient the blood-pressure may be maintained 
by giving a rectal injection of normal saline every few hours, or hypo- 
dermoclysis may be resorted to. (See Hypodermoclysis, Part III.) 

Atropine and strychnine are useful, and ether may be given subcu- 
taneously or by the mouth as a diffusible stimulant. If uremia 
threatens the use of saline by hypodermoclysis, combined with 
digitalis by the mouth, or caffeine, pituitrin, or adrenalin, may be 
resorted to to overcome renal stasis. (See article on Diarrhea.) 

CHOLERA INFANTUM. 

It is important to bear in mind that every case of cholera infantum 
is due to the excessive growth of microorganisms in the alimentary 
canal, and that in a large proportion of cases these organisms find 
entrance to the body through impure milk or water. Disturbed 
digestion due to extraneous causes or to excess of one of the elements 
of the food may be responsible. If the fats are in excess the stools are 
acid in reaction, may contain lumps of fatty soaps looking like curds 
and have a butyric acid odor. Fat curds are small or moderate in 
size, easily broken up and soluble in ether. Placed in water they 
float. When casein is in excess the odor is offensive and the stools 
often alkaline. Casein curds are large and tough, become hard in 
ether and tend to sink in water. When carbohydrates are the cause 
the stools are acid and smell like sour bread. If the nates become 
excoriated the stools are usually acid. In a certain proportion of 
cases microorganisms find the intestine a favorable place for growth 
solely because the character of the food is bad as to purity, and of 
such consistency or in such proportion that the digestive organs 
fail to deal with it properly. As a result conditions favorable to germ 
growth develop. To prevent this disorder careful feeding is essential, 
and after the child begins to convalesce careful feeding is still impor- 
tant. (See Feeding the Sick.) The organisms are those of fermenta- 
tion in some cases, or are of the type capable of causing dysentery in 
others. The latter may belong to the type called the dysentery bacil- 
lus of Shiga or that of Flexner. Both of these produce greater 
toxemia and depression than the fermentative organisms. The gas 
bacillus is not uncommon and is dangerous. It produces an acid 
stool. 

Every case of this disease is to be considered as an infectious illness, 
and every endeavor made to prevent the growth of malignant organ- 
isms in the bowel, to aid in the elimination of their toxins and as far as 
possible to support the vital forces of the patient. Hot weather pre- 
disposes a child to cholera infantum because its lowers its vitality and 
also tends to increase the growth of microorganisms in the milk. 

Diarrhea occurring in an infant in hot weather is to be regarded by 



714 DISEASES 

the physician as a fireman regards a fire. The only way to prevent 
a calamity is to regard it seriously and use every effort to prevent its 
further development. 

Absolute avoidance of milk and the use of a few drops of beef-juice 
in water every hour or two for twenty-four hours are the first orders 
as to diet. If vomiting is active and collapse is threatened, a drop or 
two of good brandy should be used in each teaspoonful of food, and 
the value of atropine as a vasomotor stimulant is not to be forgotten. 

If masses of undigested food are passed, a dose of castor oil (1 to 
4 teaspoonfuls [4.0-8.0] to a child of two years), with 20 minims (1.3) 
of paregoric, should be used to sweep out the offending materials and 
allay irritation, and be followed at once by the treatment which will be 
spoken of later. (See Sodium Citrate.) 

When the diarrhea is severe there may be much bearing down, or 
in other cases a simple running off of the liquid from the bowel almost 
without effort. Very soon, indeed, the passages become entirely 
colorless, except for a speck or two of green. The diapers have a 
peculiar mousy odor, and are characteristic, that is, they seem to be 
only wet and musty, and contain no solid matter. If closely exam- 
ined, they will be seen to be soiled by a small amount of a whitish 
substance, looking like a paste made of water and fine chalk. Such a 
passage bodes ill for the child unless treatment is instituted. The 
physician should order, at once A grain (0.003) of podophyllin for a 
child of six months, to be taken in two doses, half an hour apart, in 
20 drops of brandy with a little water. Two hours after this the dose 
should be repeated, and again in two hours more if necessary. By 
the end of the fourth hour there will be generally seen in the move- 
ments of the bowels a trace of color, and this will gradually become 
more marked if the case is to have a favorable termination. Calomel 
may be used in stead of podophyllin. 

As soon as the movements have changed from the pasty white 
motions named to those having a bilious color, then, and not until 
then, are astringents to be employed. If they are used before 
this, the diarrhea may become less for a few hours, but the child 
absorbs poisons from its alimentary canal and rapidly goes into col- 
lapse. 

The rationale of this treatment rests upon the fact that owing to the 
disease every gland connected with the alimentary canal has become 
inactive. It is absolutely necessary to bring about glandular activity 
and podophyllin, in the experience of the author, is the best remedy 
for this purpose. During the period that the podophyllin is acting it 
is well to apply a spice-plaster to the belly or to immerse the child for 
short intervals in a hot bath, if its extremities are cold, to maintain its 
bodily temperature. 

In practically every case of cholera infantum it is of the utmost 
importance to stop milk-feeding absolutely for a few days. Nothing 



CHOLERA INFANTUM 715 

in the way of food may be given, except Valentine's Beef-Juice, 10 
minims (0.6) every two hours with a little cold water, or beef-juice 
expressed from rare rump steak, until curds and undigested food are 
no longer found in the stools. 

Buttermilk, more or less diluted with water and sometimes sweet- 
ened with a little sugar, is also useful when milk feeding is begun again. 
(See also Sodium Citrate, Part II, and Casein Milk under Foods for 
the Sick.) 

When the child is feeble and poorly nourished the stopping of milk 
feeding, as detailed above, may be inadvisable. It is under these 
conditions that Bulgarian lactic acid bacillus does the greatest good, 
since it stops putrefaction and permits milk feeding to be continued. 
As many as 10 to 40 tablets may be given in the first twenty-four or 
forty-eight hours if it is to produce a positive effect, but such doses 
are rarely necessary. No so-called intestinal antiseptics should be 
given for obvious reasons while the lactic acid bacillus is used. 

The buttermilk with its lactic acid bacilli, or lactic acid bacilli 
given in tablets dissolved in water, inhibit the growth of putrefactive 
organisms, but are contraindicated if the stools are acid in reaction 
due to fermentation of carbohydrates. 

After these measures have been resorted to, and the chief object- 
namely, a bilious stool— obtained, the diarrhea may be stopped gradu- 
ally. The medicinal treatment should consist in the use of a mixture 
such as the following for a child of a year or eighteen months: 

1$ — Acidi sulphurici aromatici gtt. xxx (2.0) 

Tincturse opii camphoratse f3iij (12.0) 

Elixiris curacoee f 3ij (8-0) 

Aquse cinnamomi q. s. ad f 5iij (90.0). — M. 

S. — Teaspoonful (4.0) in a little water every two hours. 

Or, 

1$ — Acidi sulphurici aromatici gtt. xxx (2.0) 

Tincturae opii camphorata3 f 3 J (4.0) 

Fluidextracti hematoxylin fgss (15.0) 

Syrupi zingiberis q. s. ad f§iij (90.0). — M. 

S. — Teaspoonful (4.0) every two hours in water. 

The salicylate of bismuth or subnitrate of bismuth or phenolsulpho- 
nate of zinc may be tried. (See Cholera Morbus.) 

Where the vomiting is very severe and incessant, the purging pro- 
fuse but free from undigested curds, a rectal injection of starch-water, 
2 ounces (60.0), containing 10 drops (0.6) of deodorized laudanum, is 
to be employed, and at the same time | grain (0.01) of gray powder 
(hydrargyrum cum creta) given every hour if the podophyllin is not 
well retained. The gray powder may in turn be substituted by t% 
grain (0.005) doses of calomel. Very minutes doses of arsenic given 
by means of the following solution are often of service in checking the 
vomiting and purging, and may be resorted to if necessary : 

]$ — Liquoris potassii arsenitis gtt. j vel ij (0.06-0.12) 

Aquse cinnamomi f 5j (30.0). — M. 

S. — Teaspoonful (4.0) every fifteen minutes until four teaspoonfuls (16.0) are taken. 



716 DISEASES 

In some cases the remedies named above only check the diarrhea for 
the time being, and it returns as soon as they are withdrawn. In such 
a case the following is of value to restore the lost tone of the parts 
involved : 

R— Resinae podophylli . . . .. . . . gr. \ (0.03) 

Liquoris potassii arsenitis gtt. iij vel vj (0.2-0.4) 

Liquoris calcis fgiij (90.0). — M. 

S. — Teaspoonful (4.0) every five hours. Shake well before using. 

Or a powder may be used : 

1$ — Resinae podophylli gr. \ (0.015) 

Pulveris ipecacuanhae gr. j (0.06) 

Sacchari lactis gr. xx (1.3). — M. 

Fiant chartulae, No. x. 

S. — One powder every five hours. 

A very important, never-to-be-forgotten measure in cholera infan- 
tum is the 'us,e of counterirritation over the belly by means of a 
mustard-plaster (1 part of mustard flour to 8 of wheat flour) or by a 
spice-plaster. This plaster should be renewed as often as it cools, 
and kept on continuously if the skin will stand it. (See Counter- 
irritation.) 

A remedial measure which has been carried out with some success 
in the treatment of cholera infantum is the use of irrigation of the 
bowels, or rather washing out of the colon. This is accomplished by 
the use of a pint of cool water containing 1 per cent, of nitrate of silver 
or of the solution named in the article on Enteroclysis. The inflow 
tube should be of soft rubber, like a female catheter. The pressure 
used should be that of a fountain-syringe raised not more than 18 
inches above the buttocks, and the outflow should be unobstructed. 
The irrigation may be resorted to every few hours, and continued 
each time until clear fluid flows away. The solution should, of course, 
not be too cold nor too hot— say 90° F. if there is fever. (See article 
on Diarrhea.) 

Hypodermoclysis may be resorted to for collapse, but intra- 
abdominal injection (which see) or longitudinal sinus injection is 
more feasible. 

When the patient seems stuporous and has panting respirations an 
examination of the urine may reveal acetone, produced as in diabetes 
by the utilization of fats of the body to compensate for starvation. 
Under these conditions levulose or glucose may be given by the bowel 
or intravenously (see Intravenous Injections and Diabetes), or a 4 
per cent, solution of sodium bicarbonate given intravenously in the 
dose of 75 to 150 cc every five hours. It cannot be given subcu- 
taneously because if the solution is boiled to make it sterile carbonate 
of sodium is found which will produce a slough. Sodium bicarbonate 
solution should be freely given by the mouth if the stomach will 
tolerate it. 



CHOREA 717 

CHOLERA MORBUS. 

This acute, painful, rapidly exhausting disorder arises from exposure 
to cold, the ingestion of poisonous or irritating foods, exposure to 
excessive heat, and a number of similar causes. 

In reality, it may be regarded in one instance as a gastro-enteritis, 
and in another as an acute serous diarrhea associated with much pain 
of a griping, rending character. Nothing compares to counter- 
irritation and morphine hypodermically for the purpose of affording 
relief. A large mustard or capsicum draft should be placed over 
the abdomen and allowed to remain as long as it can be borne. If 
the patient knows that he has taken irritant foods, J ounce (16.0) of 
castor oil with 15 to 20 minims (1.0-1.3) of laudanum added to it, 
to prevent griping, should be employed to sweep out the offending 
masses before any other remedies are used, and be followed by an 
antidiarrhea mixture, such as the following: 

R — Acidi sulphuriei aromatici f^ij vel f3iv (8.0-16.0) 

Fluidextraeti haematoxyli f 3iv (15.0) 

Spiritus chloroformi f 5ss (16.0) 

Syrupi zingiberis q. s. ad f Siij (90.0). — M. 

S. — Dessertspoonful (8.0) every two hours. 

If the pain is very severe, the patient should be given morphine 
(gr. i [0.015]) and atropine (gr. -^ [0.0004]) hypodermically. (See 
articles on Diarrhea and Cholera, Asiatic.) 

CHOREA. 

St. Vitus' dance is a nervous affection, generally occurring in chil- 
dren, yielding to treatment quite readily in some cases, and in others 
remaining persistently severe, and even becoming worse, under the 
physician's care. 

The disease is always to be treated by the removal of all sources of 
reflex irritation, such as worms, a long prepuce if it is irritated by 
retained urine or smegma, or other trouble of this character, and in the 
avoidance of punishment or severe rebuke on the part of the attend- 
ants. This advice is given not because chorea is produced by such 
irritating conditions, but because they tend to impair the nervous 
tone of the patient. Except in that form of the disease closely associ- 
ated with or dependent upon rheumatism, the profession universally 
employs arsenic in one of its forms as a specific remedy. Generally 
Fowler's solution is used, and, unless the parents are intelligent enough 
to drop medicine carefully from a bottle or dropper, the physician 
should order a 3-ounce mixture (90.0) with 60 minims (4.0) of Fowler's 
solution, so that each teaspoonful will contain a little less than 3 
minims of the drug. Very frequently, to be effective, arsenic must 
be used in ascending doses, increased 1 minim (0.06) a day, and in 



718 DISEASES 

consequence the dilution just spoken of is to be avoided, and the 
importance of care in measuring the pure drug impressed upon the 
patient's relatives. 

When arsenic is used the physician should instruct the attend- 
ants to stop administering the drug if any puffiness under the eyes is 
seen in the morning on arising from bed, or if any pain in the bowels 
ensues, as these symptoms show that the full medicinal action of the 
drug is being felt. 

When arsenic fails, cimicifuga in the dose of 20 to 30 minims (1.3- 
2.0) of a fresh fluidextract for a child of ten years may be used as the 
next best remedy. 

When the disease is associated with rheumatism, recent or remote, 
large doses of the salicylates, particularly novaspirin, sometimes 
called tolysin, or aspirin, may be of value, and should be thoroughly 
tried. 

In some cases of chorea the muscular jerkings are so severe that 
sleep is impossible, and the patient has to be held in bed and the bed- 
covers tied down. These qases will often obtain a quiet night by the 
use of the hot pack at bedtime. (See Heat.) The child should be 
placed in a blanket previously dipped in water as hot as can be borne 
by the patient and thoroughly wrapped up in another (dry) blanket to 
retain the heat, and then be allowed to sweat. Care must be taken 
that a heat-stroke does not result, and, if sweating does not come on 
and oppression ensues, the blanket must be removed. The sheets 
should be ironed to have them warm for the patient when she is 
returned to bed, and it is often better to let her sleep between dry 
blankets. The efficacy of this treatment is increased by the use 
of a dose of bromide of sodium or potassium and a little chloral, as 
follows : 

3— Chlorali hydrati 3J (4.0) 

Sodii bromidi 3ij (8.0) 

Aquae destillatse q. s. ad fgiij (90.0).— M. 

S. — A dessertspoonful (8.0) in water every five hours for three doses. 

In other instances, 3 to 5 grains (0.15-0.3) of barbital sodium, dial 
or even luminal, grain 1 (0.06) are advantageous. 

CHOROIDITIS. 

Choroiditis, or inflammation of the choroid, may depend upon con- 
stitutional disorders, infections, toxins and traumatisms, or upon dis- 
eases in other portions of the eye. Common varieties are syphilitic, 
tuberculous and traumatic choroiditis. Like iritis and iridocyclitis a 
number of types of acute choroiditis are caused by bacterial elements 
arising from local areas of sepsis especially in connection with the 
teeth, tonsils, nasal passages and nasal accessory sinuses. 

The treatment depends upon the recognition of the cause and suit- 



COLIC 719 

able general and local medication. Mercury, iodides and alteratives, 
in general terms, are usually indicated; great care should be exercised 
to search for focal infections. Tuberculous choroiditis indicates the 
use of tuberculin in suitable cases. 

COLIC (HEPATIC). 

This exceedingly painful condition, due to the engagement of a 
gallstone in the bile-duct, is usually associated with faintness and 
nausea. 

The object of the physician must be to relieve the pain, not only 
by the use of anodynes, but also by aiding in the escape of the stone 
into the bowel. To relieve the pain a hypodermic injection of mor- 
phine, i to | grain (0.015-0.03), accompanied by t ^-q- grain (0.0006) 
of atropine, is indicated. The morphine not only decreases the pain, 
but allays spasm, and the atropine relaxes the spasm of the muscular 
coats of the ducts and allows the stone to pass through the relaxed 
passage-way. Hot applications, such as turpentine stupes, may be 
used over the liver, but relaxation is not to be obtained by the use 
of nauseating emetics, as the retching or vomiting may rupture the 
distended gall-bladder. Energetic rubbing should not be used for 
the same reason. 

For years the use of olive or cotton-seed oil has been largely 
resorted to in this affection, and while we are not sure of the manner in 
which it acts, the studies of Rosenberg and others point to the chang- 
ing of the oil into glycerin and fatty acids, the first of which liquefies 
and increases the flow of bile. Often the large dose of oil causes 
nausea, and this, by producing general relaxation, may aid in the 
escape of the stone. The oil is used during the attack of pain, and 
must be swallowed in the dose of half a pint at least; small quantities 
do not suffice. Its action may be aided and its retention in the 
stomach promoted by the addition of a dram of ether to each dose. 

Shortly after the oil is swallowed sudden relief often occurs, due, 
perhaps, to the escape of the stone into the bowel. The stools should 
then be carefully watched for gallstones, but care should be taken 
that the lumps of soap which are passed, made from the oil by the 
alkaline juices in the intestines, are not mistaken for true biliary 
calculi. 

If the pain does not yield to morphine, chloroform or ether may 
be inhaled for the relaxation of the spasm and the relief of pain. 

In the endeavor to render our treatment of a patient with gall- 
stones rational, we naturally study the causes which induce their 
formation. In the first place, a catarrhal state of the biliary passages 
favors the formation of gallstone by providing an excess of mucin, 
with the aid of which the stone may be formed ; secondly, this catar- 
rhal state is commonly associated with, or produces of itself, a dimin- 



720 DISEASES 

ished alkalinity of the bile, whereby the cholesterin becomes more 
readily precipitated, and at the same time, it would appear, causes 
the deposition of an abnormal amount of lime salts, brought from 
elsewhere in the body and passed out through the mucous membrane. 
This latter fact seems proved by the circumstance that bile itself 
contains very little lime, and that more lime is found in stones lying 
against markedly catarrhal mucous membranes than in stones not so 
situated. Again, it sometimes happens that the nidus for a stone 
consists of agglutinated typhoid bacilli in the gall-bladder or duct. 
So far, then, we have a simple, pathological process providing no less 
than three ingredients of stone-formation— namely, mucin, choles- 
terin, and stearate or some other salt of lime. There are still other 
important factors at work— namely, the systemic state, gouty or 
otherwise, which tends to stone-formation, and the stasis of the bile 
in its ducts, because the catarrhal process in the mucous membrane 
blocks its passage toward the bowel. 

Recognizing these etiological factors, it now becomes our duty to 
oppose them, and we have the following indications to fulfil : 1 . By 
causing a free secretion of bile to produce a rapid flow of fluid which 
shall be normally liquid and probably normal in its constituents. 
2. By the use of alkalies to antagonize the development of acid ten- 
dencies and to aid in the solution of mucus. 3. By regulating the diet 
prevent those hepatic and systemic disorders which tend to the forma- 
tion of stone. 4. As catarrhal states are often due to or aided by bac- 
terial infection, to produce intestinal asepsis as far as possible. 

The normal secretion and flow of bile are best brought about by 
exercise of a gentle and wisely directed nature, taken continually and 
regularly, and particularly those forms of exercise which call into play 
the abdominal muscles and diaphragm or cause hepatic movements. 
The chief and best of these is horseback riding, or, if the patient is 
too feeble for this, massage should be resorted to, the hypochondrium 
being well but gently kneaded and rubbed daily for a considerable 
period of time. If the liver seems very torpid, calomel in small 
divided doses of a fraction of a grain may be given several times a 
week, or nitrohydrochloric acid may be used. In other instances, 
where there is reason to believe that the flow is sluggish and the 
bile not sufficiently alkaline, and that catarrh and putrefactive ten- 
dencies are present, the administration of benzoate or salicylate of 
sodium, in 10- or 20-grain doses, will result in increasing the flow, 
increasing the alkalinity, overcoming the catarrh, and then arresting 
intestinal putrefaction. If the catarrhal process is very marked, 
chloride of ammonium will act even more satisfactorily. This treat- 
ment seems especially valuable when the stones that are passed are 
very dark in color, indicating that much pigment and little cholesterin 
is present. In respect to the use of alkalies, the patient should drink 
freely of those mineral waters which will provide alkaline substances, 
such as Contrexeville, Vichy, and Kronenquelle, and it is useful in 



COX J UNC TI VI TIS 721 

many such cases to relieve any tendency to constipation or duodenal 
catarrh by the administration of hot Carlsbad water before breakfast 
daily. 

In the matter of regulating the diet, all rich or fatty foods are to be 
prohibited. Meat should be used in moderation, no game ingested, 
and green vegetables largely eaten. 

Turpentine is said by some physicians to be useful to liquefy 
mucus and aid the flow of bile, and is thought by some physicians to 
cause expulsion of the stone by stimulating the walls of the ducts, 
and to dissolve the stone. The latter action is impossible. Never- 
theless, its continual use seems to prevent the formation of stone. 
Ralfe states that it is best given as follows: 

3— Olei terebinthina? TTlv (0.3) 

Syrupi acacise f §ss (16.0) 

Sodii phenolsulphonatis gr. xx (1.3) 

Spiritus setheris compositi TUxv (1.0) 

Aquae menthae piperita? q. s. f§j (30.0). — M. 

S. — To be taken twice or thrice a day. 

I would prefer adding compound tincture of lavender instead of 
peppermint-water. If this mixture cannot be retained by the 
stomach, the turpentine may be given in capsule, and followed by a 
draught of milk. 

If attacks of gallstone colic are frequent enough to incapacitate 
the patient, or if fever, pain and tenderness in the region of the gall- 
bladder is severe or constant, surgical relief is demanded. 

Finally, a most important factor in the prevention of gallstone 
formation in susceptible persons is the avoidance of exposure and wet, 
and, if possible, residence in a sunny climate during winter months. 
The existence of gallstones does not justify surgery, but if their 
existence causes severe symptoms surgical measures are indicated. 

CONJUNCTIVITIS. 

Simple Conjunctivitis, sometimes called catarrhal, acute, or muco- 
purulent ophthalmia, is characterized by congestion of the con- 
junctiva, loss of transparency of the palpebral portion, and some dread 
of light, with a discharge, sufficient only to glue the lids in the morning, 
or free and mucopurulent. In the milder stages the use of a boric- 
acid lotion (10 grains to the ounce [0.6 : 30.0]) is suitable, and the lids 
should be frequently washed with neutral soap and water; if there 
be much mucopurulent discharge, the liquid should be everted and an 
application made of a solution of nitrate of silver (from 2 to 5 grains 
to the ounce [0.12-0.3:30.0]). If the discharge becomes profuse, 
bichloride of mercury, 1 : 10,000 or mercurophen (1:8000) may be 
employed with advantage or the nitrate-of-silver solution increased 
10 grains to the ounce (0.6-30.0), the excess being neutralized with a 
solution of salt or washed away with tepid water. In place of nitrate 
46 



722 DISEASES 

of silver protargol and argyrol are much .used and may be employed 
in a strength varying from 10 to 25 per cent., according to the severity 
of the symptoms. Much inflammatory reaction in this disease may 
be alleviated by iced compresses. Patients suffering from catarrhal 
conjunctivitis should be protected from tobacco-smoke, bright light, 
dust, or any mechanical irritant. Atropine usually is unnecessary 
unless a corneal ulcer complicates the affection. The patient may 
wear smoked glasses, but in no circumstances should the eyes be band- 
aged or have poultices applied to them. Domestic medication of this 
sort may change a simple conjunctivitis into a serious and purulent 
inflammation. Topical medications other than those mentioned are 
biborate of sodium (gr. iv-viij to the ounce), alum (4 to 8 grains to the 
ounce [0.25-0.5 : 30.0]), sulphate of zinc (1 to 2 grains to the ounce 
[0.06-0.12:30.0]), which may be suitably combined with boric-acid 
solution. During the subsidence of the inflammation, and if it shows 
any tendency to become chronic, the application of an alum crystal or 
a solution of tannin and glycerin (10 grains to the ounce [0.6 : 30.0] ) is 
suitable. It should be remembered that mucopurulent conjunctivitis 
may become epidemic in crowded institutions, and great care should 
be taken to isolate cases. One soiled towel may be the source of 
infection to a great number of children. Constitutional treatment 
ordinarily is not required, but proper hygiene, fresh air, good food, 
the intelligent use of laxatives, and tonic doses of quinine are useful. 
Conjunctivitis may be associated with nasal catarrh, bronchitis, a 
general cold, eczema of the face, and the exanthemata. 

Acute contagious conjunctivitis, vulgarly known as "pink eye," 
does not greatly differ in its manifestations from ordinary simple con- 
junctivitis, except that it is more violent and is more apt to be associ- 
ated with hemorrhages beneath the conjunctiva. As its name indi- 
cates, it is highly communicable, and sometimes appears in an 
epidemic form. It is due, in the great majority of instances, to the 
Koch- Weeks bacillus. A very similar form of epidemic conjunctivitis 
is caused by the pneumococcus, and sometimes by the influenza 
bacillus. The treatment is the same as that already described. A 
solution of sulphate of zinc, 1 or 2 grains to the ounce, is preferred by 
some surgeons. 

Conjunctivitis due to the Morax-Axenfeld bacillus, although usu- 
ally subacute in character, may appear as an acute manifestation. 
Solutions of sulphate of zinc (gr. i-iv to f§ j) (0.05-0.2-30.0) are prac- 
tically specific in their action in this disease; the silver salts are of 
no use. 

Burns of the Conjunctiva.— Immediately after the accident all foreign 
particles should be removed; then a few drops of sweet oil may be 
instilled and atropine employed (suitably incorporated with liquid 
vaselin) to prevent iritis. The chief danger lies in the development of 
severe corneal inflammation and symblepharon; the latter may some- 
times be prevented by daily breaking up the granulation-tissue or by 



CONJUNCTIVITIS 723 

the insertion of a piece of goldbeaters' skin between the inner surface 
of the lids and the eyeball. The associated conjunctivitis and kera- 
titis require treatment differing in no way from that described in 
connection with other forms of these affections. 

Purulent Conjunctivitis occurs in three specific forms: In the new- 
born (conjunctivitis neonatorum, or ophthalmia neonatorum), in 
young girls (gono-blennorrhea of young girls), and in adults (gonor- 
rheal conjunctivitis, or ophthalmia). 

Conjunctivitis neonatorum is caused by the introduction into the 
eye of infecting material from some portion of the genito-urinary 
tract of the mother, at the time of or shortly after birth. The 
majority of cases, and all severe forms, are associated with a special 
microorganism, the gonococcus of Neisser, and the secretion in the 
eye of any new-born child should always be promptly examined 
bacteriologically. The prognosis is always grave in gonorrheal cases, 
but with competent medical attendance, and if the eye comes under 
treatment while the cornea is still clear, except in certain types, with 
inherent malignancy, or where depreciation of nutrition or inter- 
current illness diminish the resisting power of the child, the disease 
should be brought to a successful termination. Failure to check the 
disease or any neglect in its management may result in severe corneal 
ulceration and its sequels— leukomas and staphyloma. Conjuncti- 
vitis neonatorum is the cause of about 8 to 10 per cent, of the total 
number of cases of blindness in this country. Fully 25 per cent, of the 
inmates of asylums for the blind have lost their sight from this 
disease. In order to remove the discharge, the lids should be gently 
separated and the conjunctival sac irrigated with a saturated solution 
of boric acid, and this irrigation repeated as frequently as is necessary 
to free the conjunctival sac from purulent secretion. To check the 
discharge nitrate of silver may be applied to the everted lids once a 
day by means of a cotton mop in a strength of 2 per cent., and its 
excess neutralized with a physiological salt solution. The application 
of white vaseline to the edges of the lids is useful as a protecting agent. 
Because of its irritating qualities, and because skilled hands are not 
always to be commanded in this disease, nitrate of silver has in recent 
times been largely substituted with argyrol and protargol. Of the 
former remedy, a 25 per cent, solution should be dropped freely into 
the conjunctival sac, so that the surfaces of the inflamed conjunctiva 
are kept constantly bathed in the fluid. (See Immersion Method.) 
Argyrol has only a limited bactericidal power, but is bland, and has the 
property of floating to the surface the mucus and pus, and thus render- 
ing their removal easier than would otherwise be the case. If this 
does not check the discharge, its action should be supplemented by an 
application of nitrate of silver in the manner already described, great 
care being taken not to injure the cornea and therefore the applica- 
tions should be made by the physician himself or by a trained nurse. 
In place of argyrol, protargol in 10 per cent, solution may be sub- 



724 DISEASES 

stituted, but it is more irritating than argyrol and not superior in 
any respect to nitrate of silver. The application of cold compresses 
during the early stages is often most useful, but it requires much 
experience to determine whether cold should be used, as not all cases 
are suited to its employment. Atropine drops (0.5 per cent.) twice a 
day may be used if corneal ulcer results. Recently frequent irriga- 
tions with ice-cold normal salt solution has been recommended. 
(Heckel.) About 25 per cent, of the cases of conjunctivitis neo- 
natorum are due to microorganisms other than the gonococcus, chiefly 
the pneumococcus, and require the treatment already detailed in the 
section devoted to non-gonorrheal conjunctivitis. 

The prophylaxis of ophthalmia neonatorum is best secured by the 
employment of the method which was instituted by Crede, namely: 
As soon as the head of the child is born, the lids are carefully cleansed, 
parted, and two drops of a 2 per cent, solution of nitrate of silver are 
instilled into each conjunctival sac. Small cold compresses are then 
laid upon the lids and renewed at suitable intervals. This method 
should be employed in all infected cases and in cases from which 
the suspicion of infection has not been removed, but it is unnecessarily 
severe if previous examination has demonstrated the entire absence 
of infection. Under the last-named conditions careful cleansing of 
the lids of the eye and flushing of the conjunctival sac with a mild 
antiseptic lotion are sufficient. . Neither protargol nor argyrol is a 
suitable substitute for nitrate of silver in infected cases, but it is safe 
to reduce the strength of the nitrate of silver solution to 1 per cent. 

Gonorrheal conjunctivitis of adults, provided the patients are 
robust and the cornea unaffected, should be treated in the early 
stages by the application of iced compresses, either constantly, or 
else for twenty minutes at a time every two or three hours. Usually 
their application is inadvisable after the first thirty-six hours. Great 
care should be exercised in removing the quickly accumulating dis- 
charge in the manner already described, and this removal is facili- 
tated by keeping the conjunctival sac immersed in a 25 per cent, 
solution of argyrol. This drug, however, is in no sense a specific, 
and its action should be supplemented by a daily application of nitrate 
of silver, in the manner already described, and in the same strength. 
In place of argyrol, protargol, in 10 to 20 per cent, solution, may be 
employed in the same manner as the argyrol, and in the experience 
of some clinicians has proved of greater value than the argyrol, or 
than the argyrol plus the nitrate of silver. In the writer's experience, 
however, nitrate of silver, either with or without the addition of 
argyrol, remains a sovereign remedy. In certain severe cases, follow- 
ing the recommendation of Kalt, the disease may be treated with 
copious irrigations of permanganate of potassium, 1 : 5000, four or five 
time a day, and in suitable cases this furnishes excellent results. 
Always, if there is corneal involvement, which is only too apt to occur, 
and even before its appearance, atropine should be used with sufficient 



CONJUNCTIVITIS 725 

frequency to keep the pupil dilated and to reduce the hyperemia of 
the iris and ciliary body. Scarification of the chemotic ocular con- 
junctiva has been recommended, but must be practised with great 
care lest the cornea be injured. The prognosis is much more grave in 
this disease than in ophthalmia neonatorum, and in a very large per- 
centage of the cases, even under the best treatment, corneal ulcers 
and consequently corneal scars and even staphyloma are the result. 

Occasionally young girls are the subject of vaginitis, which in severe 
form is associated with a purulent discharge, and in hospitals and 
asylums has occasionally assumed the form of an ocular epidemic. In 
some of these cases gonococci are present in the discharge. The treat- 
ment should in all respects conform to that which has been described 
in connection with ophthalmia neonatorum. 

Chronic Conjunctivitis may result from an antecedent acute inflam- 
mation of the conjunctiva or exist as an independent affection, espe- 
cially in elderly people, in whom it sometimes becomes a troublesome 
symptom, especially if complicating cataract. The characteristic 
lesions are roughness of the papillae of the conjunctiva, swelling of the 
caruncle, and soreness of the angles of the eyelids. There are no 
granulations, although the disease is sometimes inaccurately spoken 
of as granular lids. A soothing lotion is indicated (10 grains of 
boric acid to the ounce [0.6 : 30.0] of water), to which may be added 
4 grains (0.12) of biborate of soda and for which a similar boric-acid 
lotion with 4 grains (0.25) of salt to the ounce (30.0) may be sub- 
stituted. A very suitable local application is lapis divinus (sul- 
phate of copper 1 part, alum 1 part, nitrate of potassium 1 part, fused 
together, and camphor equal to one-fiftieth of the whole added; the 
mass is run into sticks, and the application made to the everted lid. 
Other useful applications are tannin and glycerin (10 grains [0.6] to 
the ounce [30.0]) and alum cyrstal. If refractive error exist, this 
should be corrected. It is to be remembered that chronic con- 
junctivitis distinctly contraindicates any operative interference in 
the eye, as, for instance, cataract extraction. There is an interesting 
form of chronic conjunctivitis, or, more accurately, subacute con- 
junctivitis, which runs a course lasting from eight weeks to several 
months, and which is characterized by very slight objective symp- 
toms, due to the presence of the diplobacillus of Morax and Axenfeld, 
and which is promptly cured by the application of a solution of 
sulphate of zinc, 1 or 2 grains to the ounce. The conjunctival secre- 
tion of stubborn cases of conjunctivitis should always be examined 
for this bacillus. 

Lacrimal Conjunctivitis is a name given to a chronic form of inflam- 
mation of the conjunctiva associated with obstruction in the lacrimal 
duct, and characterized by a tear-soaked appearance of the eye, 
small pustules at the roots of the lashes, and a gummy discharge 
along the palpebral margin. This can be cured only by relief of the 
stricture of the nasal duct which causes it, but may be alleviated with 



726 DISEASES 

the same remedies recommended in the treatment of chronic con- 
junctivitis. 

Follicular Conjunctivitis.— A disease sometimes mistaken for 
trachoma, but having a distinct clinical difference, inasmuch as the 
swollen follicles are absorbed without the production of cicatricial 
changes in the conjunctiva— requires for its local treatment weak 
astringents and antiseptic lotions, and the application to the swollen 
follicles of an ointment of sulphate of copper (gr. \ to the dram 
[0.03 :4.0]). If the disease is stubborn, the swollen follicles should 
be crushed with suitable expression forceps. This conjunctival 
affection may prove to be very troublesome in schools and asylums. 
Sometimes it is difficult to differentiate it from trachoma. 

The disease, or one analogous to it, is sometimes produced by the 
prolonged instillation of atropine, and less frequently by eserine and 
cocaine. If this is its cause, the drug must be suspended and the 
surface painted with an alum crystal. 

Trachoma.— This disease is characterized by an inflammation of 
the adenoid layer of the conjunctiva, associated with the development 
of the trachoma bodies or granulations and enlargement of the 
papillary layer. After absorption and metamorphosis of the inflam- 
matory material, cicatricial changes develop and the disease may 
be complicated with distortion of the lid, incurvation of the lashes, 
and ulceration and bloodvessel formation in the cornea (pannus) . In 
the early stages the enlarged follicles, or trachoma bodies, are chiefly 
located in the retrotarsal folds, are of a grayish-white or yellowish 
color, and they have been compared to frog-spawn owing to their 
appearance. Later they are hidden by the swollen conjunctiva and 
changed in appearance by the metamorphosis of their contents, which 
has already been noted. In certain stages the disease, especially if 
associated with purulent secretion, is markedly communicable, and 
is therefore notably dangerous in schools, camps, cantonments and in 
any institution where large numbers of inmates are gathered together. 
Its detection by those who inspect immigrants is of the utmost import- 
ance, in order that its spiead may be limited. If the disease is asso- 
ciated, as is often the case, with a mucopurulent secretion, the con- 
junctival sac should be frequently cleansed with a saturated solution 
of boric acid, or with a solution of bichloride of mercury, 1 : 8000, or 
cyanide of mercury, 1 : 5000, and nitrate of silver, or argyrol, or pro- 
targol mav be employed to check the purulent discharge, care being 
taken that the applications are not too prolonged lest they cause stain- 
ing of the conjunctiva. After the discharge has been checked, or in 
those cases in which it does not exist, the everted lid may be touched 
with a crystal of sulphate of copper, or with a solution of tannic acid, 
30 grains to the ounce of glycerine, or with one of boroglyceride, 20 to 
50 per cent. In place of sulphate of copper, copper citrate in 5 per 
cent, ointment, introduced into the conjunctival sac with the aid 
of gentle massage, is of service. A 5 per cent, solution of sulphate 



CON J UNCTI VITIS 727 

of copper in glycerine is useful. Numerous other antiseptic and 
astringent remedies have been employed, namely, phenol, hydrastin, 
iodide of silver, ichthargon, 2 to 3 per cent., ichthyol, and, indeed, 
almost any remedy of this nature whose application is suited to the 
ocular surroundings. 

The best results, however, are obtained by surgical measures, the 
mildest of 'which consist in some form of expression operation, by 
means of which the trachoma bodies are squeezed with suitable forceps 
from their lodging place in the conjunctiva, and the lids subsequently 
treated according to the principles already enunciated. Their 
removal by vigorous rubbing with the end of the fingers covered with 
surgical gauze is performed by some surgeons. Other surgical 
procedures consist in scarification, followed by brushing of the 
conjunctiva with a solution of bichloride of mercury, 1 : 2000, electro- 
lysis, and excision of the fornix conjunctivae and in chronic cases of the 
tarsal plate. X-rays and radium are recommended by some surgeons 
in the treatment of trachoma, but suitable surgical procedures produce 
the best results and if properly applied cure a large percentage of 
cases. 

Vernal Conjunctivitis (Fruehjahr's Catarrh), characterized by photo- 
phobia, mucous discharge, granulations in the palpebral conjunctiva, 
and a hypertrophy of the tissue about the limbus, appears chiefly in 
the warm months and disappears in cold weather. The usual treat- 
ment of conjunctivitis is suitable, and the various measures described 
in connection with trachoma have been tried; but protection from 
heat and change from a warm to a colder climate are most likely 
to meet with success. The persistent use of adrenalin chloride 
(1 : 10,000) is useful. Radium is valuable, but its use requires an 
expert. Applications of fibrolysin are of value (Luedde). 

Diphtheritic Conjunctivitis may appear alone or in association with 
diphtheria of the throat and nose. The initial subjective symptoms 
are those of purulent ophthalmia; the characteristic objective symp- 
toms, a board-like infiltration of the lids with a deposit of gray mem- 
brane upon the palpebral conjunctiva. More than in any other eye 
disease destructive inflammation of the cornea is threatened. In the 
early stages the eye should be frequently cleansed with boric acid or 
bichloride of mercury solution, and atropine drops should be instilled. 
The constitutional measures for diphtheria are necessary, and the best 
treatment is the employment of injections of diphtheria antitoxin. 

Chemosis of the Conjunctiva, in which this membrane is infiltrated 
with serum, is usually a symptom of other ocular disorders, and sub- 
sides under the general treatment directed to their relief. It is a 
common sign of diseases of the nasal accessory sinuses. Angio- 
neurotic edema of the conjunctiva may appear without apparent 
cause and with marked suddenness. Good results may follow nicking 
the swollen tissues with a pair of scissors, the application of a warm, 
moist compress, and the use of astringents, especially alum. 



728 DISEASES 

Hemorrhage beneath the Conjunctiva (subconjunctival ecchymosis) 
may follow an injury, occur during a paroxysm of whooping-cough, 
and occasionally, in elderly people, may appear spontaneously. Re- 
curring subconjunctival hemorrhages in elderly people are indicative 
in many instances of renal disease, having much the same significance 
as hemorrhages in the retina. No treatment materially hastens 
absorption of the blood, unless it be massage of the globe through the 
closed lid; any associated conjunctival irritation indicates a boric-acid 
collyrium. 

CONSTIPATION. 

This troublesome state depends on a number of causes, the most 
common of which is the following of a sedentary life, devoid of 
the exercise intended to keep the intestinal and hepatic secretions 
in an active state. Another frequent cause is simple laziness, which 
causes the patient to resist the call of the bowel for evacuation until 
this part of the body becomes indolent and atonic, while modesty 
often causes constipation in females, because a woman prefers to 
suffer rather than go to a closet which may be somewhat publicly 
situated. In other instances it is due to enteroptosis, or depends 
upon deficient nerve-supply or muscular weakness and lack of secre- 
tion in the lower bowel, or upon hepatic torpor. When due to enter- 
optosis, which is more commonly met with in multipara or in stout 
women who have grown thin, abdominal support should be given by a 
belt which holds up the abdominal contents or by adhesive straps. 

Whatever the causes are, they should be sought for, and, if possible, 
removed, the physician not being content to order purgatives, which, 
while they may give temporary relief, soon lose their power. 

Further than this, it must be remembered that hygienic measures 
always take first place in the method of treatment, and, if possible, 
drugs should occupy a very secondary role. Particular attention 
should be paid to diet, and the physiology of peristalsis must be well 
borne in mind. 

It has been proved by a large number of studies, both in the normal 
intestine and by the use of purgatives, that peristalsis is almost 
entirely a reflex action depending for its existence upon the integrity 
of the nervous plexuses in the intestinal walls— namely, those of 
Auerbach and Meissner— the first of which are situated between the 
longitudinal and circular muscular fibers which they supply, the latter 
existing in the submucosa and supplying the walls of the villi, the 
glands of Lieberkuhn, and the small arteries and venules. 

It has also been found that the vagus nerve, when stimulated 
reflexly or directly, increases peristalsis, and that moderate stimulation 
of the splanchnic nerve decreases it. 1 It at once becomes evident 

1 Some persons believe that Meissner's plexus receives impulses from the walls of 
the intestine and transmits them to the motor plexus of Auerbach, which then sets 
in motion peristalsis. 



CONSTIPATION 729 

that any decrease in the normal activity of these nerves and nerve- 
centers must speedily result in constipation, and the costive condition 
consequent upon hepatic torpor is due to the fact that the intestinal 
walls do not receive the proper stimulation from the bile to set in 
motion a reflex peristaltic wave, the result of which will be evacuation. 
This fact rests upon the results of direct experiments, which prove the 
bile to be primarily an intestinal stimulant, antiseptic, and promoter 
of secretion. 

Other series of experiments have shown that the circulation of the 
blood through the intestines greatly influences peristalsis, and dis- 
orders in the blood-supply readily bring on intestinal disorder. 

The deductions to be drawn from these facts are many. In the 
first place, it is evident that the maintenance of an active, normal 
circulation of blood in the abdomen and a free pouring out of bile 
from the liver and gall-bladder are necessary to a healthy peristalsis; 
and we find that, aside from drugs, there are a number of remedial 
measures which may be resorted to according to the means of the 
patient. By far the best of these is horseback exercise for at least an 
hour a day or every other day, which by the motion actively stirs up 
and excites the abdominal viscera as no other measure can do. If for 
any reason horseback exercise is impossible, then abdominal massage, 
carried out by a capable "rubber," is to be tried, the hands following 
more particularly the course of the ascending, transverse, and descend- 
ing colon, the kneading movements being also applied to the hypo- 
chondriac regions. If neither of these measures can be used, then 
the patient must resort to those gymnastic movements which involve 
the abdominal muscules, either by the use of dumb-bells or pulleys, 
such as are sold under the name of "home gymnasiums," or by bend- 
ing the body forward, backward, and laterally, with the fists pressed 
into thehypogastrium. (For movements, see Inhalations, Part III.) 

At the same time that these measures are directed the diet of the 
patient must be so regulated that the food shall contain a large 
amount of residue— that is, after digestion enough of the husk of the 
grain or enough vegetable fiber must be left free in the intestines to 
form a stimulus to the intestinal wall as it slips over the mucous mem- 
brane. If a meat diet is largely used, so little residue is left after 
digestion that constipation ensues, but if vegetables are largely eaten, 
the reverse is the case. No better evidence of this can be adduced 
than the hard, clay-like passages of the dog and the soft passages of the 
cow. Very often a plateful of cracked wheat (wheaten grits) eaten at 
breakfast each morning, or the use of bran bread, will relieve a ten- 
dency to chronic constipation. In these cases milk as a prominent 
article of diet is to be avoided above all things, since it is almost 
entirely assimilated and leaves no residue, though it supplants other 
foods. Green or canned corn is of great service. Fruits do good in 
constipation in one of two ways— they contain either residual mater- 
ials or sufficient vegetable acid salts to be laxative. Figs, by reason 



730 DISEASES 

of their many small seeds, which scrape the mucous membrane during 
peristalsis, are particularly valuable, and apples, prunes, dates, and 
tamarinds are all useful. Agar-agar is useful and liquid petrolatum 
of the heavy type is beneficial when the stools are dry, as it acts as a 
lubricant and keeps the stools soft. It must be remembered that 
strawberries, raspberries, and blackberries are generally constipating 
rather than purgative. In regard to drink, nothing is so good as a 
glass of cold water taken on arising in the morning or just before 
breakfast, or, if the cold cannot be borne, than a glass of as hot water 
as can be swallowed with comfort may be substituted. Coffee is 
constipating to most persons, largely because of its empyreumatic 
oil, and tea has the same tendency because of its tannic acid. Brandy, 
as every one knows, is distinctly constipating, and whisky possesses 
so little power to the contrary as to be devoid of influence in either 
direction. Beers differ in their properties, some of them increasing 
and some of them decreasing intestinal activity. 

The patient suffering from constipation should go to stool regularly 
after breakfast every day even if the attempt is abortive, and so train 
the bowels to having a movement at this time. 

The use of drugs for the relief of constipation is capable of division 
into two parts: First, the employment of remedies to unload the 
bowel, which has become filled; second, the use of drugs which will so 
influence the intestines as to cause evacuation and produce normal 
activity, or, in other words, drugs which will cure the tendency 
instead of giving temporary relief. Of the first class we find the var- 
ious purgative salts, jalap, colocynth, senna, mercury, castor oil, and 
rhubarb ; of the second class, aloes, cascara sagrada, phenolphthalein, 
rhamnus frangula (buckthorn), phosphate of sodium, and small doses 
of podophyllin. The physician should bear in mind that defecation is 
a normal physiological act which must be continued all through life, 
and it is almost as foolish to stimulate the bowel continuously to 
peristalsis as perpetually to employ heart stimulants or respiratory 
excitants. 

Although habitually employed by many persons in daily doses, 
the purgative salts if given in concentrated form are exceedingly 
harmful in such instances, rapidly losing their power and decreasing 
the patient's strength by the abstraction of liquids and salts from the 
blood. They often produce anemia when constantly used. These 
salines are to be employed simply to unload the bowel when an excess 
of fecal matter has accumulated or when irritant materials are to be 
swept out of the alimentary canal. In some cases of pelvic congestion 
associated with constipation magnesium sulphate may be given 
by enema in the proportion of 2 ounces (60.0) of the salt, 1 ounce 
(30.0) of glycerine, and 4 ounces (120.0) of water. In other instances, 
particularly where plethora exists, a course of Pluto water, Abilena, 
or other waters, which depend chiefly upon magnesium and sodium 
sulphate for their activity, is of service. When used habitually they 



CONSTIPATION 731 

should be diluted with hot water and given half an hour before break- 
fast. The patient should then take some exercise before taking food. 
Jalap, colocynth, and senna are not to be used constantly, as they are 
too active and the reaction from their effects causes constipation. 
Rhubarb is commonly used, but is of its class peculiarly unfitted to its 
task. Although it purges, it is distinctly astringent, and is therefore 
constipating afterward. 

Mercury is exceedingly harmful if used continuously as a purge, and 
may be the cause of much ill health, of decayed teeth, and of digestive 
troubles. Castor oil is notorious for its tendency to cause ultimate 
constipation. It is to be used to clear out the bowels and not be 
employed continuously. 

Of the curative class of laxatives none compares to cascara sagrada, 
particularly in the form of the aromatic fluidextract or cascara 
cordial. Originally this drug, as prepared, was very bitter, but it is 
now made almost tasteless by certain manufacturers. This is the 
only drug which alone moves the bowels and at the same time tends 
to make future passages more easy and regular; the dose is 10 to 
40 minims (0.6-2.6) of the fluidextract or 1 to 6 drams (4.0-24.0) of the 
cordial. There is almost no griping produced by it. For regula- 
tion of the bow T els of young children, particularly if the case have a 
tendency to rickets, phosphate of sodium in the dose of 5 to 10 grains 
(0.3-0.6) in milk is a useful laxative, and the same salt may be used 
in 30- to 60-grain (2.0-4.0) doses in adults. Phenolphthalein in the 
dose of 1 to 2 grains (0.06-0.12), taken at night, is an excellent laxa- 
tive. The two remaining drugs of this class, aloes and podophyllin, 
should always be used in combination with other non-purgative drugs, 
as is seen in the following formulae : 



Or, 



1$ — Aloes purificati .... 

Extracti nucis vomicae 

Extracti physostigmatis . 

Extracti belladonna? . 
Fiant pilulae, No. xx. 
S. — One pill at night or night and morning. 



gr. xx vel xl (1.3-2.6) 

gr. iv (0.25) 

gr. hj (0.2) 

gr. iv (0.25).— M. 



3} — Resinae podophylli gr. ij vel iv (0.12-0.25) 

Extracti nucis vomicae gr. iv (0.25) 

Extracti physostigmatis gr. iij (0.2) 

Extracti belladonnae gr. iv (0.25). — M. 

Fiant pilulae, No. xx. 

S. — One pill night and morning. 

The object of using several of these drugs is seen at a glance. The 
nux vomica acts as a bitter tonic and stimulant, and prevents sub- 
sequent atony of the mucous membrane, as well as increases reflex 
action, and consequently improves peristalsis; the physostigma is a 
tonic to the unstriped muscular fiber and gives it strength; the bella- 
donna aids peristalsis by depressing the inhibitory fibers of the 
splanchnic nerves, by allaying spasm, and by decreasing griping. In 
using these drugs, aloes and podophyllin, it should be remembered that 



732 DISEASES 

aloes is slow and acts particularly on the lower bowel, and that 
podophyllin is the slowest in the list of purges. (See Phenol- 
phthalein.) 

In obstinate constipation we are sometimes forced to resort to the 
compound cathartic pill of the U. S. P., or its modified form known as 
the Pilula Cathartica Vegetabilis (see Colocynth). After the bowels 
have been well emptied by this pill we can often regulate them by 
cascara sagrada with or without other laxatives, and by prescribing 
a proper diet and exercise. 

In the flatulence of old persons associated with constipation a little 
asafcetida and capsicum should be added to the pill of aloes just named. 

In some instances constipation arises from reflex irritation as from 
ovarian or bladder trouble or from chronic lead poisoning. This 
form of constipation may resist all purgatives and yield to opium or to 
tobacco, which quiet reflex action. In patients with enteroptosis 
constipation the use of a supporting belt is often of great service. 

In still other instances no definite focus of reflex irritation is found, 
but the constipation seems to be due to fixation or spasm. In these 
cases I have obtained excellent results from benzyl benzoate. 

The employment of enemata as a routine practice is to be dis- 
couraged. In cases where it is necessary to use them for temporary 
relief and to get rid of flatulence, a little soap, common salt, or a few 
drops of turpentine may be added to the water. 

The injection of glycerin (1 to 2 ounces [3.00-60.0]) has been 
largely resorted to, either pure or diluted one-half, and this method 
has been improved upon by the use of glycerin suppositories con- 
taining many drops of the drug. Glycerin acts in these cases as 
an irritant to the mucous membrane, and causes secretion by this 
means and by its abstraction of water from the tissues by reason 
of its hygroscopic powers. It is capable, however, of causing a good 
deal of rectal irritation in some persons. 

Much has been written on auto-intoxication resulting from consti- 
pation, and radical surgical operations resorted to for relief. I 
heartily endorse these words of Woolley: 

1. Absorption of bacteria and other substances from an unhealthy 
bowel may produce serious symptoms. 

2. A surgical operation for intestinal stasis is not justifiable except 
as a last resort. 

3. There is no definite information in the literature to show that 
surgical procedures, made for intestinal stasis, have been more 
successful than medical (including hygienic) ones. 

4. Many cases in which symptoms are attributed to intestinal 
stasis are suffering from focal infections entirely outside the intestinal 
tract. Such infections are illustrated by pyorrhea alveolaris, chronic 
tonsillar infection, and chronic infections of the antra and sinuses of 
the head. 



CORY Z A 733 



CORNS. 



These troublesome formations are best treated by the use of sali- 
cylic acid, the following formula being applied night and morning for 
several days, after which the part should be well soaked in hot water, 
when the entire corn will readily come away, but in some cases several 
attempts will be necessary: 

]$ — Acidi salicylici gr. xxx (2.0) 

Extracti cannabis gr. x (0.6) 

Collodii f5ss (16.0).— M. 

S. — Apply with a camel-hair brush. 

The same acid may be used in alcohol, and lactic acid in the same 
proportion is often of service. 

In the so-called "soft corns," with much inflammation, the foot 
should be washed and dried, and a saturated solution of nitrate of 
silver, 60 grains (4.0) to 2 drams (8.0) applied to the part every four 
or five days. 

CORYZA (ACUTE). 

The treatment of coryza of the acute variety, the form which most 
f requently presents itself to the physician for relief, is followed in many 
instances by such marked amelioration of the symptoms and shorten- 
ing of the attack as to encourage medical interference. It must be 
remembered, however, that the duration of the condition before the 
patient presents himself has much to do with the prognosis, for if the 
tissues of the nasal chambers have become boggy and swollen with 
exudate recovery must be more delayed than if remedies are applied 
in the early stages of the catarrhal process. The local treatment con- 
sists in the following measures for relief: By means of an atomizer 
a few minims of a 4 per cent, solution of cocaine are sprayed into 
the nostrils, the patient's head being well tipped back. If there is 
any contraindication to cocaine, adrenalin 1 : 10,000 may be used in 
many cases. After the constringing influence of the cocaine has 
shrunken the congested mucous membrane, so that the patient can 
draw air through the nostrils, the nasal chambers should be washed 
clean of mucus by means of the following lotion in an atomizer: 

]$ — Sodii chloridi gr. xv (1.0) 

Acidi borici gr. x (0.6) 

Sodii boratis gr. x (0.6) 

Aquae destillatae f §iij (90.0) — M. 

It is well to use a solution of antipyrine 2 to 4 grains to the ounce 
(0.12-0.25 : 30.0) of water as spray to prolong the effect of the cocaine. 
Under no circumstances should the antipyrine be used without the 
cocaine preceding it, as the pain is too severe. 

The parts being thoroughly cleansed, a fine spray of the following 
should be used as antiseptic, sedative, anesthetic, and protective: 

1$ — Mentholis gr. viij (0.5) 

Camphorae gr. v (0.3) 

Petrolati liquidi f 5 J (30.0).— M. 



734 DISEASES 

In this prescription the menthol exerts an anesthetic effect, and pro- 
longs the constriction of the parts produced by the cocaine, so avoiding 
the secondary capillary dilatation due to that drug. The camphor 
exercises its well-known soothing influence, and the albolene protects 
the membrane from dust and irritants. 

The internal treatment consists, in the very beginning of the attack, 
of the use of the formula for this purpose composed of belladonna, 
camphor, and quinine, and recommended in the article on Camphor. 
Much benefit often follows the use of 30-grain doses (2.0) of sodium 
bicarbonate every two hours for three doses. A hot foot-bath, with 
mustard in it, and the taking of a hot drink, such as lemonade with 
whisky in it, on going to bed, are useful. Often 20 to 30 minims 
(1.3-2.0) of sweet spirit of nitre added to this drink will increase its 
diaphoretic effect. In other cases, particularly in strong, hearty men, 
5 to 10 grains (0.3-0.6) of Dover's powder at bed-time will be better. 
In still other cases Tully's powder, made with codeine instead of 
morphine, is very successful. 

This line of treatment is of little value after secretion has been fairly 
established, and in its place supportive measures are indicated. Small 
tonic doses of quinine, 2 to 4 grains (0.12-0.25) three times daily, some- 
times combined with the use of 5 to 10 grains (0.3-0.6) of chloride 
of ammonium, as prescribed in the article on Bronchitis, are useful. 
Where much headache is present full doses of the bromide of potas- 
sium or sodium are to be given, and the spray treatment already 
named for the purpose of cleansing the nasal chambers is to be per- 
sisted in while the attack lasts, but the cocaine ought not to be 
employed at this time unless absolutely needed. (See Camphor.) 

CROUP. 

(See Diphtheria.) 

CROUP (SPASMODIC). 

As this is a spasm of the glottis depending for its causation upon 
catarrh of the mucous membrane of the larynx, and as it is due most 
commonly to some reflex irritation, such as dentition, indigestible 
food, or sudden atmospheric changes, or to rachitis, or to the presence 
of postnasal adenoids, the treatment is both prophylactic and curative. 
Prophylaxis consists in the avoidance of cold; the use of a simple diet, 
particularly at the evening meal; the rendering of the air of the 
bedroom moist by means of steam, or at least by the avoidance of 
dust-laden, furnace-heated air, and by the removal of dental irritation 
and nasal hypertrophies, which make the child a "mouth-breather." 
Iron and arsenic are useful tonics if the child is anemic and rachitic. 
Much relief can be provided such patients by having them sleep in a 
"bronchitis tent." (See article on Bronchitis.) Small doses of the 
bromides, chloral, belladonna, or opium may be resorted to at bed- 



CYSTITIS 735 

time. A very useful prescription for this purpose is that which 
follows: 

H— Sodii bromidi 5J (4.0) 

Syrupi lactucarii foij (60.0). — M. 

S. — Teaspoonful to a dessertspoonful (4.0-8.0) on going to bed, and once or twice 
during the night if needed. 

When the attack is present, a cold cloth should be wrapped about 
the neck and the child placed at once in a hot bath, the air of the 
room being moistened by the steam escaping from a kettle of boiling 
water or by pouring water upon unslaked lime. It is also useful to 
disseminate the fumes of menthol through the air of the room by 
heating some crystals in an iron spoon. If the fumes are strong 
enough to produce a distinct odor, they are present in" sufficient 
amount. If the paroxysm is very severe, a few whiffs of amyl nitrite 
may be employed. 

CYSTITIS (ACUTE). 

If, by reason of exposure to cold, injury, the introduction of foreign 
bodies, such as dirty catheters, or the presence of gonorrhea or other 
disease due to an infection, an acute inflammation of the bladder 
ensues, it is accompanied by a sensation of weight and vesical fulness, 
by pain, tenesmus, and inability to retain the urine. Sometimes the 
last-named condition may be reversed and retention of urine be 
present. 

If the general system responds to the local inflammation, as evi- 
denced by increased arterial excitement and fever, aconite, in full 
doses of the tincture, should be used, and it should be combined with 
small amounts of sweet spirit of nitre and citrate of potassium, as 
follows : 

1$ — Tincturse aconiti f 5iij (12.0) 

Spiritus ffitheris nitrosi f§j (30.0) 

Liquoris potassii citratis . . . . q. s. ad f Bvj (180.0). — M. 

S. — Dessertspoonful (8.0) every four hours until all fever ceases and the pulse 
is quiet. 

At the same time a hot compress should be applied over the bladder, 
but it should not contain turpentine or any irritant substance which 
may be absorbed from the skin and when eliminated by the kidneys 
irritate the bladder-walls. Leeches may be placed upon the perineum 
or cups applied to the region of the sacrum. In some cases belladonna 
may be used with or without aconite in the dose of 15 to 20 minims 
(1.0-1.3) of the tincture three times a day, and it is worthy of note 
that this drug is particularly serviceable in cystitis due to cold. If the 
urine is acid and irritating, 5 minims of potassium hydroxide every 
four hours, or the citrate or acetate of potassium, may be used. If 
there is much pain and bearing-down, an enema of 30 minims (2.0) of 
tincture of deodorized opium in 2 .ounces (60.0) of starch- water may 
be employed, or the opium may be given in suppository. 



736 DISEASES 

Sometimes a belladonna suppository is of more service, and an 
iodoform suppository will often relieve the pain by its local anesthetic 
effects. Hot enemata, without any drugs, are often valuable as a 
means of relief, and a hot sitz-bath is very efficacious. Cannabis, 
if an active preparation can be had, may be better than opium in 
some cases to relieve the pain, since it seems to affect the bladder 
favorably. The other curative measures are hygienic, and consist 
in maintenance of the recumbent posture, absolute physical and 
mental rest, avoidance of all foods which are stimulating, as highly 
seasoned dishes, and abstinence from all varieties of alcoholic 
beverages. 

Should the inflammation be severe enough to become purulent, the 
physician should order phenyl salicylate in the dose of 10 grains (0.6) 
three times a day. This drug, being broken up in the bowel into 
phenol and salicylic acid, is so eliminated that it renders the urine 
antiseptic; or in other instances, if the urine is alkaline and phos- 
phatic, hexamethylenamine (urotropin or uritone) in the dose of 5 to 
10 grains (0.3-0.6) should be given in capsule after food or drink three 
or four times a day. A 10 per cent, solution of silvol or argyrol may 
be used to wash the bladder daily. 

Laxatives are to be employed with persistence if the bowels are 
confined, and saline purgatives in the early stages are generally better 
than vegetable purges. 

Quinine should not be used against the fever, as it is contra- 
indicated, owing to its irritant effects upon the bladder. 

CYSTITIS (CHRONIC). 

Given a case of chronic cystitis it must be borne in mind that a 
pathogenic microorganism is usually the cause, or at least is respon- 
sible for the continuance of the condition. The urine should be 
examined bacteriologically and if a specific organism is found in pure 
or even in dominant numbers, an autogenous vaccine should be given, 
or, if this is not possible, a stock vaccine should be used. (See Vac- 
cines.) If the colon bacillus is present the urine should be rendered 
acid by the use of acid sodium phosphate (which see) and hexamethyl- 
enamine given freely. In other infections alkaline diuretics are 
usually better. Obstinate cases which do not yield to treatment 
should be examined by means of the cystoscope and treated locally, 
as when the trouble is due to a tuberculous ulcer or to a growth. The 
prostate should also be examined to determine if it interferes with 
proper emptying of the bladder and urethral stricture is to be sought 
for. 

The drug treatment of chronic cystitis consists in the use of remedies 
which will stimulate the diseased mucous membrane, cause a normal 
secretion of mucus, and so influence the urine that the mucus already 
formed will be passed out and the fluid rendered alkaline or acid, as 



CYSTITIS 737 

may be desired. When the secretion of mucus in large amount is 
persistent, the urine should be rendered alkaline by the use of potas- 
sium hydroxide or the citrate of potassium. The bitartrate of potas- 
sium, unlike the other vegetable salts of potassium, such as the acetate 
or bicarbonate, is eliminated as the bitartrate of potassium, and, as it 
is acid, cannot be employed. 

We acidify the urine when it is necessary to dissolve the phosphates 
and to prevent deposits in the bladder. The three good drugs for this 
purpose are hexamethylenamine (urotropin or uritone) in the dose of 
10 grains (0.65) three or four times a day, acid sodium phosphate in 
the dose of 20 to 40 grains (1.3-2.6), or benzoate of ammonium 10 to 
20 grains (0.6-1.3) three times a day. The rule may be laid down 
that if the urine is high-colored and is strongly acid, alkalies are useful; 
whereas if it is light in color, but loaded with phosphates, urotropin 
or uritone should be employed. Hexamethylenamine (urotropin or 
uritone) may be given to prevent decomposition of the bladder 
contents, and if so acid sodium phosphate should also be used. 

The remaining remedies which are employed internally in chronic 
cystitis are those which are directed to the improvement of the mucous 
membrane of the bladder, and consists of buchu in the form of the 
fluidextract in the dose of \ to 1 dram (2.0-4.0), well diluted; arbutin 
or ursin, 3 to 5 grains (0.2-0.3) ; or the fluidextract of uva ursi, dose 
30 minims to 1 dram (2.0-4.0). All of these are better fitted for the 
treatment of subacute than chronic cystitis, as they are not sufficiently 
active for the chronic forms. 

In cystitis of a very chronic type, with great vesical atony, strych- 
nine is of sendee, and drop-doses of tincture of cantharides do great 
good. Turpentine may also be used with advantage in 5- to 20- 
minim (0.3-1.3) doses, as may also the oils of eucalyptus, sandalwood, 
cubebs, and copaiba. 

One of the best measures for the relief of chronic cystitis is to irri- 
gate the bladder daily with warm normal saline or water containing 
bichloride of mercury in the proportion of 1 : 10,000, as this washes 
away pus and mucus, and prevents irritation. Solutions of nitrate of 
silver have been used with great success where the urine is muco- 
purulent, and Thompson recommends the use of a solution of the 
strength of 1 grain to 4 ounces (0.06-120.0) of water, gradually 
increased to 2 grains to the ounce (0.12 : 30.0) . Others, such as Gard- 
ner, Richardson, and Potter, recommend the use of stronger solutions, 
5 grains to the ounce (0.30 : 30.0) of water, claiming that while these 
amounts may produce serious effects in some instances, they are very 
efficacious in obstinate cases. The physician should have at hand a 
solution of common salt, which he should inject into the bladder at 
once if the effect of the silver solution is too painful or seems excessive. 
This treatment is suited only to the most chronic cases. 

A weak solution of mercurol and a saturated aqueous solution of 
chloretone may also be used with advantage. 
47 



738 DISEASES 

All these measures are suitable for the treatment of cystitis in the 
male and female, but it is to be noted that injections into the female 
bladder are made much more readily than into that of the male, 
because of the shortness of the female urethra. In either case the 
operation is best performed by attaching a small funnel to a soft- 
rubber catheter and filling the bladder by raising the funnel when full 
of water above the patient's belly. 

DIABETES INSIPIDUS. 

Diabetes insipidus is a chronic profuse urinary flow dependent 
upon some disorder of the innervation of the kidney or upon disease 
of the pituitary body. In most cases, however it depends upon a 
disordered action of the pituitary body. 

The best results follow the hypodermic use of pituitrin, but Langdon 
highly commends the use of full doses of valerian. How the latter 
acts is not known. 

DIABETES MELLITUS. 

In the treatment of this affection it should be remembered that it 
is not a disease in itself, but a symptom of several morbid processes. 
For this reason a remedy which succeeds in one case may fail in 
another. 

The treatment of diabetes mellitus is both dietetic and medicinal, 
of which the more important part is the diet, since diabetes is a state 
of the body in which the system is unable to utilize properly the carbo- 
hydrate portions of the food, and as a result sugar is passed out in 
the urine. Glycosuria, or the mere presence of glucose in the urine, 
is not diabetes, although if it is constant it may be the early stage of 
the disease. Manifestly, both of these states are to be treated by 
decreasing the intake of those articles which will produce glucose, 
namely, the starches, and therefore the carbohydrates are to be 
greatly cut down in all antidiabetic diet-lists; but changes in the diet 
should be very gradually instituted in those severely ill, since sudden 
cutting off of starches may cause marked nutritional disturbance and 
precipitate an attack of diabetic coma. In these patients the sudden 
deprivation of carbohydrate foods results in production of carbo- 
hydrate substances from the body proteids and fats, and it is essential 
to administer foods containing starch to protect the tissues of the 
patient and to prevent the production of poisons which are produced 
by this tissue breakdown. This is a most important point to be 
remembered. 

Given a case of diabetes the physician should obtain a record of the 
case by studying it for several days before he institutes dietetic treat- 
ment. After he has determined the amount of urine passed daily, 
the sugar output, and the presence or absence of diacetic acid or ace- 
tone, he may proceed to cut down the starch intake gradually. If 



DIABETES MELLITUS 739 

three or four days after this the urine becomes entirely free from sugar, 
the patient may be given approximately 100 grains (3 ounces) of bread 
in twenty-four hours. If no sugar appears in the urine 200 grams 
(6 ounces) of bread are given the next day, and if within the next 
twenty-four hours sugar appears it would seem evident that the 
patient can deal with 100 grams, but not with 200, and 100 should be 
allowed him not only to please his palate but to protect him from 
tissue breakdown and diabetic coma. If the complete withdrawal 
of starch does not check the sugar excretion, small portions of starch 
should be given for the reason just given. The danger does not lie 
in the escape of sugar in the urine, but in upsetting metabolism. 
Fats, to some extent, take the place of starches. Butter, if freely 
used, should first be carefully washed with' water, containing a little 
soda, to free it from bodies such as butyric acid, which can be readily 
converted into acetone-like bodies. We must prescribe fat meats, 
and, contrary to old teaching, order rich milk instead of skimmed 
milk. 

Diabetics can often utilize a single carbohydrate in fairly large 
amounts without glycosuria when they are unable to take several 
starches. The most easily dealt with starches for them have been 
found to be oatmeal and potato. Tests must be made until the 
amount of these carbohydrate substances that can be taken daily, 
without increasing glycosuria, are determined. Often a "starvation 
day," when no starch is taken, will enable the patient to deal with 
larger amounts of starch afterward. 

The following articles are allowed: 1 Meats of all kinds (except 
liver), eggs, fish, cheese, butter, and cream; oyster-plant, asparagus 
(?), tomatoes, almonds, pecan nuts, butternuts, walnuts, and cocoa- 
nuts; string-beans, beet tops, radishes, mushrooms, lettuce and water- 
cress, cauliflower, spinach, and onions. Celery and cucumbers may 
also be permitted. 

Of the foods and drinks to be avoided, we have all forms of sugar, 
all forms of starch, such as ordinary flour, cornmeal, arrowroot, sago, 
tapioca, barley, carrots, beets, parsnips, pie-plant, peas and beans, 
chestnuts, and most of the fresh fruits, cider, beers, champagne, 
sweet wines, and honey. (See Levulose.) 

The patient should have a diet so arranged as to give all the calories 
he needs without starch, and this may be accomplished if he takes 
daily 2 ounces (60 grams) of butter, 2 eggs, 2\ drams (10 grams) of 
olive oil, 1 ounce (30.0) of fat cheese, 1 quart (960 cc) of milk, and 1 
ounce (30.0) of alcohol. This will give the man 1600 calories, and he 
needs but approximately 2400 to 3000, which can be obtained by 
additional food. (See Diastase.) 

Comparatively recently two heroic methods of treating diabetes 

1 It is worthy of note that certain persons having a slight glycosuria without 
serious injury, waste under a limited diet, and require ordinary fare to support the 
body plus the sugar drain. 



740 DISEASES 

mellitus have been brought forward.. If they are to be instituted I 
believe the physician should have preliminary tests as to the patient's 
state, as already pointed out, but their advocates do not insist on 
this. Guelpa's method consists in absolute starvation with free 
purgation by means of a saline laxative for two or three days, after 
which time the patient is often sugar-free. After this the patient is 
gradually put back on a vegetable and starch diet, but the amount 
of protein allowed is very limited. 

The so-called Allen method is based upon the principle that the 
function of the pancreas is impaired and that this organ must be given 
complete rest, and the plan is as follows: For forty-eight hours 
after admission to the hospital the patient is kept on an ordinary diet 
to determine the severity of his diabetes. I think that this is too 
short a period, since my experience has shown that this determination 
can only be approximately made by a study covering from five days to 
a week. At the end of two days the patient is put to bed and no food 
allowed save whisky and black coffee, the whisky being given in the 
coffee, 1 ounce of whisky every two hours from 7 a.m. to 7 p.m.— in 
other words, 6 to 8 ounces a day. Sodium bicarbonate is sometimes 
given in the dose of 2 drams every three hours, if there is much 
evidence of acidosis, as indicated by strong acetone and diacetic 
reactions in the urine, or a strong acetone odor to the breath. It is 
stated, however, that in most cases this is not necessary and that there 
is no danger of producing coma by starvation. If this is true it 
controverts the belief heretofore universally held by medical men, and 
until further evidence is adduced, I prefer to remain on the side of 
caution by regarding suddenly induced starvation as dangerous. This 
is particularly true if the patient has suffered from the malady for a 
long time and of those who have an acetone breath or an exceedingly 
rapid form of the disease. 

The patient is kept in bed and starved until the urine is sugar- 
free. The disappearance of sugar is rapid. If there has been 5 or 6 
per cent., after the first starvation day it goes down to 2 per cent., 
and on the third day the patient is sugar-free, or certainly by the 
erid of the fourth day this occurs. It is claimed that there may be a 
slight loss of weight amounting, perhaps, to 3 or 4 pounds, and Allen 
goes so far as to say that a moderate loss of weight in most diabetics 
is to be desired. Here, again, I think that this statement is too dog- 
matic. It may be true of obese patients, but it certainly is not true of 
the emaciated ones, particularly if the patients are young. The 
question also arises as to how many patients are able to take nothing 
but whisky with black coffee to the extent of 6 to 8 ounces a day with 
advantage. I have yet to find one. It may be true that the sedative 
effect of this amount of alcohol overcomes the nervous effect of large 
quantities of black coffee, but many diabetics suffer very intense 
nervous irritability, which is often emphasized by distressing pruritus, 
and I question whether this so-called diet would be tolerated, even if 



DIABETES MELLITUS 741 

the stomach and the liver were able to deal with this amount of 
alcohol without distress. Certainly, there are a very large number of 
persons who cannot take this amount of whisky, even if it is diluted 
with a considerable quantity of food or drink, without inducing gastric 
and hepatic symptoms. 

When the patient is sugar-free he is allowed to get up and is placed 
upon vegetables containing approximately 5 per cent, of carbohydrate. 
These vegetables are thrice boiled with changes of water, so that their 
actual carbohydrate content is reduced probably one-half. A moder- 
ate amount of butter-fat is permitted. If the patient eats very 
heartily of green vegetables, even if they are thrice boiled, he may 
obtain more carbohydrate than his system can utilize. The typical 
dietary for the first day of feeding is as follows: 

BREAKFAST. 

String beans, 4 heaping tablespoonfuls. 
Asparagus, 4 heaping tablespoonfuls. 
Tea or coffee. 

DINNER. 

Carrots, cooked, 2 heaping tablespoonfuls. 
Spinach, cooked, 3 heaping tablespoonfuls. 
Tea or coffee. 

SUPPER. 

Cucumbers, 12 slices. 
Celery, 6 pieces 6 inches long. 
Tea or coffee. 

In diet list No. 2 cabbage and onions are substituted for some of 
the vegetables already named, and on the third and fourth days the 
variety of green vegetables is increased as to number and cream and 
butter added. The diet, day by day, becomes somewhat more gen- 
erous, so that diet list No. 12 contains: 

BREAKFAST. 

Bacon, 2 slices 6 inches long. 
1 egg. 

Spinach, 2 heaping tablespoonfuls. 
Coffee, butter and cream. 

DINNER. 

Steak, one, very small. 

Salt pork, 4 slices. 

Cabbage, 3 heaping tablespoonfuls 

Onions, 3 heaping tablespoonfuls. 

Butter, cream and tea. 

SUPPER. 

1 \ ounces of beef balls. 

Celery salad, 2 tablespoonfuls; olive oil. 

Tomatoes, 2\ tablespoonfuls. 



742 



DISEASES 



In addition the patient is allowed during the day 2 ounces of butter 
and 10 tablespoonfuls of 40 per cent, cream. If, however, oxybutyric 
acid, or diacetic acid, is present in the urine in any amount, and par- 
ticularly if any evidence of diabetic stupor is seen, it is to be recalled 
that as these substances are largely derived from the breaking down 
of fats they must be used with care if at all. If, as the diet is grad- 
ually increased, sugar appears, the diet is again cut down, and it is 
important to remember that the increase in the proteid elements of 
diet may increase the elimination of sugar. 

Joslin, in his excellent book on " Diabetes," gives the following table 
which shows the carbohydrate content of various vegetables suitable 
for diabetics : 

DIET. 

Strict Diet. — Meat, Fish, Broths, Gelatine, Eggs, Butter, Olive Oil, Coffee, 
Tea and Cracked Cocoa. 

Foods Arranged Approximately According to Percentage of 
Carbohydrates. 



Vegetables 








(Fresh or canned) 










5 per cent. 1 


10 per cent. 1 


15 per cent. 


30 per cent. 


Lettuce 


Tomatoes 


Onions 


Green peas 


Potatoes 


Cucumbers 


Brussels 


Squash 


Artichokes 


Shell beans 


Spinach 


sprouts 


Turnips 


Parsnips 


Baked beans 


Asparagus 


Water cress 


Carrots 


Canned lima 


Green corn 


Rhubarb 


Sea kale 


Mushrooms 


beans 


Boiled rice 


Endive 


Okra 


Beets 




Boiled 


Marrow- 


Cauliflower 


Kohl-rabi 




macaroni 


Sorrel 


Egg plant 


Pumpkin 






Sauerkraut 


Cabbage 








Beet greens 


Radishes 








Dandelion 


Leeks 








Swiss chard 


String beans 








Celery 


Broccoli 










Fruits 








Ripe olives 


contain 20 per cent. 


Lemons 


Apples 


Plums 


fat 




Oranges 


Pears 


Bananas 


Grapefruit 




Cranberries 

Strawberries 

Blackberries 

Gooseberries 

Peaches 

Pineapple 

Watermelon 


Apricots 

Blueberries 

Cherries 

Currants 

Raspberries 

Huckleberries 


Prunes 



See p. 647 for nutritional balance and proportions of foodstuffs in normal 
persons. 

I think that the average physician will find some difficulty in 
making his patients adhere to the rigid rules described above, but, for 
that matter, he usually finds it difficult to make his diabetic patients 
adhere to any rules. That Dr. Allen and his followers have been 
able to produce excellent results by this method is undeniable. That 

1 Reckon available carbohydrates in vegetables of 5 per cent, group as 3 per cent., 
of 10 per cent, group as 6 per cent. 



DIABETES MELLITUS 743 

it can be applied in the sweeping manner which its description indi- 
cates, I very much doubt. This plan of treatment savors too much 
of rigid routine applied in a disease which of all others lends itself but 
poorly to any absolute hard-and-fast plan. 

Joslin and others have found it advantageous in cases of long stand- 
ing and severity, without otherwise changing the habits or diet, to 
begin treatment by omitting fats in order to decrease the source of 
acid bodies, after two days to cut out proteins, and simultaneously 
to cut the amount of carbohydrates to 10 grams, and then if the 
urine is not sugar-free to starve the patient as above described. 

The wide divergence of methods of diet in diabetes shows how little 
we still known of the pathology of this diseases. (See Foods for Sick.) 

A useful artificial milk will be found described in Part III. 

The treatment of diabetes by drugs is varied by the condition of 
the patient, the cause of his disease, and the quantity of sugar in the 
urine. While the drugs most commonly employed are used in many 
instances without any knowledge of how they act, and have each of 
them warm supporters among authorities, much of the treatment 
must depend upon whether or not a rheumatic or gouty taint is the 
cause of the trouble, or whether it is due to high living and little 
exercise, producing a plethoric, congested, overloaded system. In the 
first class of cases iodide of potassium and the salicylates will be most 
serviceable; in the second class, a restricted diet, moderate exercise, 
and purgation to relieve engorgement of the hepatic and gastric 
veins may be needed. In the cases of gouty diabetes, where relief 
does not follow the use of the iodides and colchicum, resort must be 
had to arsenic and lithium citrate or carbonate, a combination pecu- 
liarly adapted to such a condition according to several authorities. 
Indeed, arsenic is a sheet-anchor with many practitioners in all forms 
of diabetes, and should be given in fairly large, constantly repeated 
doses for a long time. A very much larger body of medical men rely 
on opium or one of its alkaloids, such as morphine or codeine. The 
former is used in the dose of \ to \ grain (0.015-0.3) three times a 
day; the latter, 1 to 5 grains (0.06-0.3) three times a day, and the 
writer has found them very useful. The morphine is by far the more 
powerful for good, but some patients who are diabetic must take 
large ascending doses of opiates to get good results. (See article 
on Opium.) In cases depending upon a gouty diathesis the use of 
salicylic acid is often of value, the dose being 10 to 15 grains (0.6- 
1.0) three times a day. 

In those cases of diabetes in which diet will control the disease the 
best clinicians insist that drugs should be avoided, for when opium or 
any of its alkaloids are used it is eventually necessary to give increas- 
ing doses, which finally become enormous, as much as 7 grains (0.45) 
of morphine a day being taken by some persons. Once having begun 
the use of opiates in severe cases, it is very dangerous to stop them, 
for clinical experience has shown that many of these patients waste 



744 DISEASES 

rapidly and generally break down when this is done. In regard to 
the time of day at which to give the morphine or codeine, they are gen- 
erally given about one hour after meals. Under these circumstances 
the drugs seem to decrease diuresis more than if the dose precedes the 
meal; further than this, the stomach is not disordered. In some 
cases results will be obtained from opium when its individual alka- 
loids fail. Careful observation of the patient should be carried out 
to determine the proper beginning and subsequent doses, and if at 
first the opiates fail to give relief discouragement should not be felt. 

Unfortunately, we have little positive knowledge as to the causes 
of diabetes, and in consequence cannot explain the manner in which 
opium, codeine, or other drugs produce relief. 

The excessive thirst of diabetes can be best allayed by the use 
of alkaline waters containing non-purgative salts. It is useless to 
cut off the water-supply, to the production of great suffering, but 
the patient should use moderation in drinking so far as possible, 
because the overloading of the stomach tends to disturb digestion. 

In cachexia comes on, iron, strychnine, bitter tonics, and the lacto- 
phosphates of lime and sodium are to be used to support the circula- 
tory and nervous systems. Tea and coffee and all forms of food 
needing sweetening may be rendered palatable by the use of saccharin 
or of glycerin. The former passes through the body unchanged; the 
latter increases the glycogen in the liver, but checks the formation of 
sugar. 

When toxic symptoms such as mental hebetude develop there is 
always present beta-oxybutyric acid in the blood and tissues, and for 
this reason the coma is said to be due to acidosis. This term has 
given rise to much error, it being though that the blood is acid and 
that the symptoms can be corrected by neutralizing the acids by the 
use of alkalies. As a matter of fact there is no actual acidity and the 
problem may be stated as follows : In health oxygen is carried to the 
tissues where the carbon is oxidized and the resultant carbon dioxide 
is carried, chiefly as bicarbonate of sodium, to the lungs where the 
bicarbonate gives off the C0 2 and carbonate of sodium returns to the 
tissues to repeat the process. In diabetic acidosis the carbonate is 
lacking and, so although the blood carries the oxygen to the tissues the 
C0 2 which is found is not removed, and so the oxygen cannot be used 
for either the normal process of oxidation nor for the destruction of 
beta-oxybutyric acid. The patient becomes dyspneic, not for lack 
of oxygen, but because he cannot get rid of C0 2 and cannot use his 
oxygen. The blood does not appear dark in hue as in ordinary 
dyspnea because its oxygen is present, and this is one of the reasons 
why oxygen inhalations do no good. In other words, the use of 
injections of sodium carbonate or sodium bicarbonate do good not 
by neutralizing an excessive acidity but by enabling the process of 
oxidation to go on. While it is true that carbonate of sodium is 
theoretically the better salt practically the bicarbonate is to be pre- 



DIARRHEA AND DYSENTERY 745 

ferred because it is not caustic and can be given safely in larger 
amounts, and it should be given by mouth or intravenously until the 
urine is alkaline. 

In severe cases of diabetes in which coma is feared because of a 
sudden increase of acetone in the urine or in which mild premonitory 
drowsiness is present, bicarbonate of sodium should be given in full 
doses, as much as ^ to 1 ounce (16.0-30.0) a day, and a full carbo- 
hydrate diet be instituted, boiled rice being one of the best starches 
to employ. Levulose or dextrose in solution may be given freely by 
the mouth, by the rectum, and even intravenously; as much as J to 
1 gram to the kilo of body weight. When given by the rectum the 
proportions are 15 grams to 1000 of water at the rate of 30 to 40 
drops to the minute. (For method, see Peritonitis, Part IV). When 
given intravenously it is best dissolved in normal salt solution in the 
strength of 5 per cent. When given by the rectum salt solution should 
not be employed, and the direct enema or drop method may be used. 

Diabetic coma is a most dangerous complication of this disease, and 
should be treated as actively as our knowledge of its cause permits. 
In addition to the measures just described Stadelman insists upon the 
employment intravenously of 150 cc. of normal salt solution to 
which 7.2 grams of sodium carbonate and 4.6 grams of sodium bicar- 
bonate have been added. The injection is continued until the urine 
is alkaline. Unfortunately, the statistics of this method of treatment 
are not good so far as permanent recovery is concerned, but some form 
of transfusion should be used. (See Transfusion.) As the condition 
is a typical toxemia, a full dose of sulphate of magnesium or sulphate 
of sodium should be given, to aid elimination by the bowels if they are 
loaded with feces. Otherwise purgatives should not be used, as they 
possibly concentrate the poisons in the blood. Hypodermic injections 
of ether should be resorted to to support the heart. If hypoder- 
moclysis is resorted to carbonate of sodium must not be used as it will 
cause sloughing, and if sodium bicarbonate solution is so employed 
it must not be boiled, as boiling changes it into the carbonate. 

DIARRHEA AND DYSENTERY. 1 

The term diarrhea is applied, perfectly correctly, to all forms of 
intestinal disturbance accompanied by the passage of liquid stools, 
and its meaning, "to run through," expresses the state it represents. 
The treatment of each form of diarrhea depends upon its cause, 
and no case can be intelligently treated in which the physician fails 
to recognize this aspect of the case. Diarrhea is but a symptom, 
not a disease, and must be regarded solely as an evidence of intestinal 
disorder. 

While the same drugs are prescribed in many forms of the trouble, 

1 The articles on Cholera, Cholera Morbus and Cholera Infantum should be care- 
fully read in connection with this article. 



746 DISEASES 

we may divide the cases of diarrhea into four classes, as follows: (a) 
Those in which the laxity is due to a catarrh, acute or chronic, of the 
intestinal mucous membrane, causing the passages to contain mucus; 
(b) those in which, owing to disordered innervation, a profuse out- 
pouring of liquid takes place from the bloodvessels into the intestinal 
lumen; (c) those in which, owing to disease, the glands fail to prepare 
juices to digest the food properly; and finally (d) those cases in which 
ulceration causes irritation and bloody purging. 

The treatment of the catarrhal form first named consists primarily 
in regulation of the diet, which should be made up chiefly of milk, 
boiled or predigested, or of milk whey, and in the administration of 
castor oil or other mild purge, such as sulphate of magnesium, to 
sweep out fermenting food and mucus. Enough laudanum should 
accompany this oil to prevent griping, and it is well to add bicarbonate 
of sodium, grains 20 to 30 .(1.3-2.0) to the dose, both to aid the 
action of the oil and to render the bowel alkaline in reaction (normal) 
instead of acid, as caused by the fermentation abnormally present. 
A mustard plaster or other counterirritant should be applied to the 
abdomen. Often in the milder forms of mucous diarrhea this is all 
that is needed, but more frequently it must be followed by the use 
of tonics and astringents, such as nitrate of silver and hyoscyamus, 
in the following pill : 

B/, — Argenti nitratis gr. ij (0.12) 

Extract! hyoscyami . gr. v (0.3). — M.. 

Fiant pilulse, No. x. 

S. — One three times a day. 

Or, 

1} — Plumbi acetatis gr. ij (0.12) ^^fe 

Extracti opii gr. ij (0.12). — M. ^^ 

Fiant pilulse, No. x. 

S. — One three times a day. 

If these stop the diarrhea, yet there still seems to be a tendency for 
it to return or atony is present, we should use a pill containing the 
extract of chiretta or employ nitrohydrochloric acid, or, better still, 
dilute nitric acid and compound tincture of cardamoms, because the 
constant tendency to relapse indicates a deficient secretive action 
on the part of the intestinal glands, which these remedies are prone 
to improve: 

Jfc— Acidi nitrici diluti f3j (4.0) 

Tincturse cardamomi compositae . . . . . f S i J (60.0) 

Tincturse gentianse compositae f 5ij (60.0). — M. 

S. — Dessertspoonful (8.0) every four hours. 

In the second form of diarrhea named— that in which serous or 
watery purging is present— the treatment is radically different. In 
these cases the bloodvessels of the gut are relaxed and leaking, and 
must be contracted and made, so to speak, water-tight. This dilata- 
tion may result from fear ("nervous diarrhea"), from exposure to 



DIARRHEA AND DYSENTERY 747 

cold, or from exhaustion, extreme heat, and irritating food. If from 
irritating foods, these are generally swept out in the first flush of 
liquid. 

The measures to be adopted consist in those directed to the con- 
traction of the dilated and relaxed bloodvessels and the restoration 
of the proper nerve-supply to the parts. 

As the splanchnic nerves are the vasomotor nerves of the intestine 
as well as the inhibitory nerves of peristalsis, it is evident that drugs 
must be used which will cause stimulation of these fibers, and the 
chief of these is found to be opium, which diminishes intestinal peri- 
stalsis and secretion by just such an influence. In the same way 
small doses of volatile oils are of service, and camphor and spirit of 
chloroform may be used. As there is relaxation, astringents are indi- 
cated; and as sulphuric acid is not only astringent, but is eliminated 
by the lower bowel, it is peculiarly serviceable. We find, therefore, 
that the following prescription fulfils every indication: 

T$ — Acidi sulphurici aromatici f 5ss (16.0) 

Fluidextracti hsematoxyli f3ij (8.0) 

Spiritus chloroformi f giv (16.0) 

Syrupi zingiberis q. s. ad f §iij (90.0). — M. 

S. — Teaspoonful (4.0) in water every two or three hours. 

If desired, tincture cf kino or gambir may be used in lieu of the fluid- 
extract of hsematoxylon, or paregoric substituted for the spirit of 
chloroform. 

1$ — Acidi sulphurici aromatici 5iss (6.0) 

Spiritus chloroformi f3ij (8-0) 

Tincturse opii camphor atae f §ij (60.0) 

Syrupi zingiberis fgiv (120.0). — M. 

S. — Dessertspoonful (8.0) in water every two hours. 

Or, 

3— Tincturse kino fgj (30.0) 

Tincturse gambir compositse f 5j (30.0) 

Misturse cretae fgiij (90.0) 

Aquse cinnamomi q. s. ad f 5vj (180.0). — M. 

S. — Shake well before using. Tablespoonful (16.0) every three hours. 

In some instances these attacks appear to depend upon hepatic 
disorder, and the only cure is to be obtained by the use of 2 to 6 
grains (0.12-0.4) of mercury with chalk (hydrargyrum cum creta) or 
calomel given in J to \ grain (0.01-0.03) doses until 1 or 2 grains 
(0.06-0.12) have been taken. What is said of intestinal disorder from 
lack of secretion under the heading of Cholera Infantum applies very 
forcibly to these cases, and diarrhea may persist for weeks, or only 
temporarily be held in check by the most powerful drugs, until the 
physician thoroughly flushes the intestine with bile by the use of 
calomel. 

For the purpose of establishing intestinal antisepsis, phenyl sali- 
cylate (salol) may be used. In other cases phenolsulphonate of zinc 
in the dose of from 1 to 4 grains (0.06-0.25) in powder or capsule is 
beneficial. Phenvl salicvlate combined with chalk mixture mav also 



748 DISEASES 

be advantageously used. (See prescriptions under Salol.) It is 
doubtful if true intestinal antisepsis can be produced by drugs; and 
if it can, they probably destroy useful benign organisms as well as 
those which are malignant. 

Wood has highly recommended the use of 20 grains (1.3) of bismuth 
powder containing a minim or two of phenol. 

The regulation of the diet, which should consist in sterilized milk 
or koumyss, the former being predigested, is of the greatest import- 
ance. 

The after-treatment consists in the use of tonics and a carefully 
regulated diet, which should be largely composed of milk and milk 
foods. When putrefaction is present the lactic acid bacillus is useful. 

The third class of cases consists chiefly of children who pass fetid, 
"mousy" smelling stools in summer diarrhea, with green, spinach-like 
masses, semi-digested food and which have distinct lientery. These 
cases may be due to deficient glandular action in any part of the 
alimentary canal, and are often cured by the use of pepsin and hydro- 
chloric acid to aid the gastric processes. In other instances the 
duodenum is at fault, and should be stimulated by small doses of 
nitrohydrochloric acid, or by podophyllin in the dose of -fa to ^o grain 
(0.0012-0.0015), with a little milk-sugar, or given in alcoholic solution. 
Similarly, ipecac in powdered form may be used in the dose of J to | 
grain (0.015-0.03) three times a day. In the case of children who are 
sufferers from rickets, lime-salts and common salt should be freely 
given. (See Cholera Infantum.) 

The fourth type, generally known as dysentery, is due in nearly 
all cases in the temperate zone to the microorganism of Shiga, bacillary 
dysentery, and to the drinking of impure water, exposure to heat or 
cold, and the use of improper food. It is in most cases a very obsti- 
nate form of diarrhea, requiring much skill and patience for its cure. 
Usually it is a good plan to start treatment with \ ounce (15.0) of 
castor oil to sweep out the bowel. (See Antidysenteric Serum, Part 
III.) Absolute rest in bed, heat or counterirritation over the belly 
and a diet of whey or thin boiled rice is to be ordered. Milk, if curds 
appear in the stools, is forbidden. There are three remedies which 
are far above all others in value. The first of these is sulphate of 
magnesium; the second, sulphuric acid; the third, calomel. 

In bacillary dysentery ipecac is useless and Flexner's polyvalent 
vaccine or Shiga's serum may be tried. (See Antidysenteric Serum.) 

The magnesium salt should be used in a special manner to be effec- 
tive. (See Magnesium Sulphate.) If calomel is used, it must be 
given in full purgative amounts, but is contraindicated if much weak- 
ness is present. 

In amebic dysentery there can be no question that emetine is the 
nearest approach to a specific that we possess, both as a cure and to 
prevent complications. (See Ipecacuanha, Part II.) 

The important points to be remembered, aside from the use of 



DIARRHEA AND DYSENTERY 749 

emetine in amebic dysentery, are that there is often an associated 
bacterial infection and that the ameba deeply buried in the floor 
of the ulcers cannot be reached by colonic injections. The best treat- 
ment would seem to be: (1) The intramuscular dose of emetine 
hydrochloride in the dose of J to f grain (0.03-0.04) once a day; 
and (2) the control of excessive purging by full doses of bismuth 
subcarbonate. If purging is not very excessive the use of magnesium 
sulphate and aromatic sulphuric acid (see Magnesium Sulphate) may 
be resorted to as in bacillary dysentery. Large rectal injections of a 
solution of quinine in the proportion of 1 : 3000 may be used, as this 
drug destroys the amebse. (See Ipecacuanha, Part II, and Entero- 
clysis, Part III.) As Vedder has shown that nitrate of silver in so 
weak a solution as 1 : 300,000 kills the Ameba dysenteries, it can be 
employed for irrigation purposes with advantage, associated with 
emetine hypodermically. Some practitioners assert that the simul- 
taneous use of arsphenamine or neoarsphenamine is essential. In 
obstinate chronic cases, even if they are very feeble, the best treat- 
ment is appendicostomy with irrigation of the colon through the 
opening. 

If the passages are slimy and bloody, 211 o" grain (0.0003) of bichloride 
of mercury every hour or two is of service, and if much blood is present 
high rectal injections of hamamelis water and water, half and half, are 
of value. The following mixture may be gently introduced into the 
bowel in feeble cases: 

I^ — Sodii boratis 3j (4.0) 

Tincturae benzoini 3J (4.0) 

Spiritus camphorse f 5j (30.0) 

Aquae ferventis Oij (960 cc). — M. 

Recently the injection of water or medicaments into the bowel for 
the purpose of influencing the intestinal wall has given way to irri- 
gation by means of an inlet and an outlet tube. The inlet tube should 
be attached to a fountain syringe, and the outlet tube be long enough 
to reach to a vessel by the side of the bed, and of sufficient caliber to 
carry off flaky mucus. In many cases of dysentery of a mild form 
rectal irrigation will suffice, but if the entire colon is involved higher 
injections are necessary and the use of an outlet tube is not feasible. 
The irrigation should be continued until the returning fluid becomes 
perfectly clear and free from foreign particles but great care should be 
exercised not to. employ too great pressure. The fountain syringe 
should not be more than eighteen inches or two feet above the anus. 
Probably the best solution to employ for irrigation where much mucus 
and pus is present is one of bichloride of mercury, 1 : 5000. When 
this is used, a pure water injection or one of 1 : 30,000 should follow 
it, in order to prevent absorption of too much mercury into the 
system. If for any reason the effect of the bichloride is feared, boric 
acid may be used in the proportion of 1 dram (4.0) to the pint (480 
cc), or 15 grains (1.0) of phenolsulphonate of zinc added to 1 quart 
(960 cc.) of hot water be injected. 



750 DISEASES 

If the ulcers are very old and chronic, nitrate-of -silver injections, 
of the strength of 10 to 20 grains (0.6-1.3) to the pint (480 cc) of 
water, may be employed in large bulk, a salt solution being at hand 
for the altering of the silver salt if the local action which ensues is too 
severe. 

DIARRHEA (CHRONIC). 1 

This is one of the most obstinate conditions which the physician 
is called upon to treat. It may be due to nervous irritability of the 
bowels, so that the entrance of food or drink sets up an excessive 
peristalsis which so hurries the food and drink through the alimentary 
canal that digestion and absorption are imperfectly performed. 
Chronic diarrhea may also be due to chronic intestinal catarrh, to 
ulcerations of the small or large intestine, as after typhoid fever, or 
to rectal disease, which reflexly causes hyperperistalsis. Fissure of 
the anus often causes persistent diarrhea by reflex irritation. In 
those cases due to hyperperistalsis an advantage is often gained by 
directing the patient to take as little liquid as possible, particularly 
at meals, and to avoid coffee or other stimulants to reflex activity. 
Highly seasoned foods are also to be avoided. Meats should be 
preferred to vegetables, and an absolute diet of peptonized milk may 
be ordered, the milk being given in tablespoonfuls every few minutes, 
rather than in large amounts. The patient should remain in bed. 
Counterirritation, constant and as severe as the patient can stand, 
should be used over the abdomen. Suppositories and rectal injections 
seldom benefit this class of cases, but a pill composed as follows may 
be useful : 

1$ — Argenti nitratis gr. iv (0.25) 

Extracti hyoscyami gr. x vel xxx (0.6-2.0) 

Extracti opii gr. ij vel iv (0.12-0.25).— M. 

Fiant pilulse, No. xx. 

S. — One pill one hour before each meal. 

This pill or capsule should be coated with phenyl salicylate so that 
it will pass through the stomach before dissolving. 

In other instances some of the astringent prescriptions given under 
the article on Diarrhea and Dysentery are better than the above. 

If the catarrhal state is persistent, no remedy compares to the 
chloride of ammonium, dose 5 grains (0.3) every four hours in fluid- 
extract of liquorice and water. Where the catarrhal state is exceed- 
ingly chronic and obstinate it is well to employ 3- to 5-grain (0.20-0.3) 
doses of potassium iodide. In many cases where the condition of 
mucous diarrhea becomes chronic it is necessary to resort to entero- 
clysis (Part III) and the treatment needed in cases of chronic intesti- 
nal catarrh. 

In the cases due to ulcers of the rectum injections of nitrate of 
silver, 2 grains to the ounce (0.12 : 30.0), are of value, particularly if 

1 Read with this article those in Diarrhea and Dysentery and Enteroclysis. 



DIPHTHERIA AND MEMBRANOUS CROUP 751 

followed by a 5- or 10-grain iodoform suppository. Operative pro- 
cedure against anal fissure will often cure a diarrhea due to this cause. 

In cases of so-called morning diarrhea abstinence from liquids 
before going to bed the night before and a very dry and small break- 
fast are to be strongly recommended, with rest in bed during the 
morning hours. 

Dried sulphate of iron in pill is useful in cases of diarrhea with 
anemia. 

DIPHTHERIA AND MEMBRANOUS CROUP. 

Diphtheria is at first a distinctly local disease, the membrane in the 
upper air-passages forming a nidus from which the entire body ulti- 
mately becomes poisoned by the toxins of the microorganism peculiar 
to the malady. While it is a fact that in some cases of membranous 
pharyngitis or laryngitis the true Klebs-Loeffler bacillus cannot be 
found, it is a fact that all cases should be treated as if they are true 
diphtheria, since in this way much good can be done, and no harm 
follows if the malady fails to develop. 

The best local application to the throat is peroxide of hydrogen. 
A cotton swab should be soaked with the undiluted 10- or 15-volume 
solution and pressed against the mucous membrane which is diseased; 
or, if this cannot be done, a spray, from a glass atomizer, of the 
strength of 1 : 4 of water may be employed. The effect is often 
extraordinary. After a few applications the false membrane appears 
to exist only in disorganized shreds. If the nasal chambers become 
affected, a tepid solution of ordinary salt (7: 1000) should be used in a 
spray or by means of a fountain syringe. The child is placed with its 
hips on the lap of one nurse and its head on the lap between the knees 
of another, the dress of the nurse being protected by a rubber sheet 
and the nasal cavities irrigated. The position of the child should be 
on its side, not on its back, and the face should be turned down 
sufficiently to allow the liquid, after entering the upper nostril, to flow 
out the lower one with ease, the child breathing through its mouth. 
The applications should be made as frequently as the membrane 
forms. 

A local application which has been much used is that of Loeffler. 
He directs that the mucous membrane shall be carefully wiped off by 
a pledget of cotton, and after this is done that a second pledget dipped 
in the following solution shall be pressed against the diseased area 
for ten seconds at three-hour intervals; menthol 2\ drams (10 grams) 
dissolved in 9 drams (36 cc) of totuol, to which are added 1 dram 
(4 cc) of liquor ferri chloridi and absolute alcohol 2 ounces (60 cc) . 
This solution, if kept in a dark glass bottle, well stoppered, will keep 
for months. The author prefers to use peroxide of hydrogen in all 
cases, as it is efficacious and painless, whereas the application of 
Loeffler's solution is apt to be very painful. 



752 DISEASES 

The local use of iodine, phenol, and similar irritating and poisonous 
substances is not justifiable. 

Antitoxin Treatment.— This treatment excels all others in efficacy 
and usefulness, and should displace all other plans of treatment 
except the local applications. Of all the extraordinary advances 
made in pathology and therapeutics, the introduction and proof 
of the value of antitoxin in cases of diphtheria is perhaps most 
worthy of note. (For the study of Antitoxin itself, see Antitoxin, 
in Part III.) 

At the present time all manufacturers of antitoxin put up their 
product in hermetically sealed bulbs, or in special containers from 
which the serum may be directly injected without the use of an extra 
syringe. The advantage of this plan is that the physician is saved 
the trouble of sterilizing a syringe and can use a fresh piece of appa- 
ratus for each injection (Fig. 128). 




Fig. 128. — The large end is securely closed by the rubber plunger itself, which is 
provided with fa"*?protective flange; over this is fitted an aluminum-capped cork 
(shown above the finger-rests) with a central perforation through which the solid metal 
piston-rod passes — to be screwed into the threaded metal socket in the rubber plunger. 
The perforated cork, with its rigid metal cap, serves to hold the rod parallel to the 
glass barrel when under pressure, so there is no oblique action and no danger of break- 
ing the glass. The needle end is closed by a rubber stopper which is paraffined in 
place, effectually excluding the air. The needle, with its flexible rubber connection, 
is placed in a tapered glass tube in such a manner that the point cannot come in con- 
tact with the glass and thus become blunted. The illustration shows the container 
after being emptied of its contents and with all attachments in place. The flexible 
needle connection fits snugly over the neck of the container and is held in position by 
a spearhead flange. When attachment is made it should be pressed up close to the 
shoulder. The finger-rests are of metal attached to a metal ring which slips over the 
glass bulb and rests against a flange of glass of double thickness; they afford a sure 
grip, making this device almost equal to a regular syringe in safety and convenience 
of manipulation. 

The great bulk of antidiphtheritic serum as compared to the small 
quantity of fluid used in ordinary hypodermic injections is a very great 
disadvantage, and many efforts have been made to concentrate the 
serum. The fact that the globulins of the serum either contain the 
antitoxin or at least are associated with it, has led to the separation 
of these globulins from the serum, and they have been found equally 
effective. Antidiphtheritic globulins are now on the market in two 
forms, the liquid and the dry. The liquid globulins hold 3000 units 
of antitoxin in about one-third the bulk of ordinary serum of equal 
strength. The dry globulin appears in small vials and is to be dis- 
solved in sterile water, the injection being given by the ordinary hypo- 



DIPHTHERIA AND MEMBRANOUS CROUP 753 

dermic syringe instead of using the combined container and injector 
used for serum or for liquid globulin. The small bulk of this dried 
product is a great advantage for physicians who are not near a base of 
supplies, as the tiny vials containing it can be readily carried in a 
pocket case for an indefinite time. Care that the water used is sterile 
is, of course, essential. It is claimed by many that the use of globulins 
is far less likely to be followed by erythematous rashes and joint pains 
than is the use of ordinary serum. Each vial of the dried globulin 
contains 3000 units, but the vials of liquid globulin vary from 500 to 
3000 units in their content. The strength is, of course, marked on 
each container. 

The dose of antitoxin serum is to be judged by its known strength 
or power of conferring immunity and by the severity of the disease and 
the susceptibility of the patient to the infection. 

The following dose table is based upon the authority of the De- 
partment of Health, City of New York (Bulletin, June 3, 1916): 

THERAPEUTIC DOSES IN UNITS. 

Infants (under 2 Children (under 15 Adults, 90 pounds 

years) 10 to 30 years) 30 to 90 and over in 

Nature of case. pounds in weight. pounds in weight. weight. 

Mild 2,000 to 3,000 3,000 to 4,000 3,000 to 5,000 

Moderate. . . . 3,000 to 5,000 4,000 to 10,000 5,000 to 10,000 

Severe 5,000 to 10,000 10,000 to 15,000 10,000 to 20,000 

Malignant . . . 10,000 to 15,000 15,000 to 20,000 20,000 to 40,000 

Cases of laryngeal diphtheria, moderate cases seen late at the 
time of the first injection, and cases of diphtheria occurring as a 
complication of the exanthemata should be classified and treated as 
"severe" cases. In all cases a single large dose of the proper amount, 
as indicated in the schedule, is recommended, because the antitoxin 
remains in the blood for several days. Repeated doses do no harm 
but little good if the first one is adequate, but if the patient has 
been sensitized by previous doses, divided doses are safer. (See 
Anaphylaxis, p. 755.) Park states that Avhen antitoxin is given hypo- 
dermically it takes two days to get its full effect whereas the intra- 
venous dose is effective at once. It is to be recalled, however, that if 
a dose has been given on another occasion or the patient is naturally 
sensitized the intravenous injection is more dangerous so far as 
anaphylaxis is concerned. 

When given intravenously the serum must be clear and warm 
and injected not faster than 1 cc to the minute, in a vein of the arm 
as a rule. 

It has been urged against serums containing over 250 units per cubic 
centimeter that their use is apt to be followed by untoward effects, 
such as skin eruptions and local irritations. On the other hand, if the 
weaker serums are employed, such large amounts have to be given that 
very considerable swelling of the area in which the injection is given is 
produced, and, of course, valuable time is lost before the whole dose is 
48 



754 DISEASES 

absorbed; whereas if serums containing high immunizing power are 
employed, the small dose is quickly absorbed. In urgent cases of 
nasal or laryngeal diphtheria the stronger serums are indicated, 
whereas in the more moderate cases the lower grades of strength may 
be used. 

The author cannot too strongly urge upon the reader the vital 
importance of using antitoxic serum early and freely. The reports 
in which it has been condemned are imperfect and unreliable. It 
has been claimed by some persons that since the use of antitoxin 
more cases of complications or sequelae are met with than ever before. 
The reason is manifest, viz., that before antitoxin was used all the 
very malignant cases died, whereas a large percentage of these are now 
saved, and suffer from lesions which if antitoxin had not been used 
would have been fatal. Every patient who apparently suffers from 
the disease should receive this remedy, so potent for good and so 
lacking in harmful qualities even when given to non-diphtheritic 
persons. The physician who can obtain the serum and does not use 
it is remiss in his duties. 

Much depends upon the early use of the remedy, for after degen- 
erative changes have taken place in the heart and kidneys the damage 
is done. Statistics show that in cases which receive the antitoxin on 
the first day the mortality is often only 3 to 5 per cent., whereas with 
each day of delay the percentage rises, so that when it is not given 
until the fourth day the mortality may be as high as 40 per cent. As 
the use of antitoxin does no harm, it should be employed in all doubt- 
ful cases of diphtheria without waiting for a bacteriological diagnosis. 

When the antitoxin is given, general improvement usually takes 
place in twelve to thirty-six hours, and the temperature falls. The 
spread of the membrane is arrested and its separation soon begins. 

Individuals who are in direct contact with diphtheria, particularly 
if they are children, should receive an immunizing dose of 1000 units 
accompanied by a dose of toxin-antitoxin. The immunity conferred 
by the antitoxin lasts about three to four weeks, whereas that induced 
by toxin-antitoxin lasts about three years or longer. This latter 
immunity, however, takes several weeks to develop, and for this 
reason the simultaneous use of antitoxin is essential to bridge this 
period, the toxin-antitoxin being too slow for immediate protection. 
Toxin-antitoxin consists of diphtheria toxin (80 per cent, of the L+ 
dose) neutralized by 1 unit of antitoxin. The dose of toxin-antitoxin 
is 1 cc hypodermically repeated every five days for three doses. This 
diphtheria prophylactic is now placed on the market in sealed bulbs 
and syringes, properly labelled as to dosage. The whole question of 
the use of immunizing doses is, however, to be decided in many 
instances by the Schick test (see page 756), because many persons 
are naturally immune. 

In a small proportion of cases the injection of antitoxin serum is 
followed by the development, within a few hours or even after several 



DIPHTHERIA AND MEMBRANOUS CROUP 755 

days, of urticarial or erythematous rashes and swelling and pain about 
the joints. The joint symptoms may not appear for ten days. 
These symptoms are more prone to develop when high-potency serums 
are employed, and in very rare cases may be so severe as to be fatal. 
Indeed, a number of cases are on record in which death has ensued, 
the alarming symptoms consisting of sudden flushing and cyanosis 
of the face, severe dyspnea, and rapidly developing unconsciousness 
with signs of pulmonary edema. Death has taken place within five 
minutes of the injection. It is difficult or impossible to determine 
beforehand what cases will, because of idiosyncrasy, suffer in this 
manner, save that asthmatics and patients of a marked lymphatic 
type seem more prone to it than others, but if a minute dose of 
antitoxin given intradermally, not hypodermically, results in a sharp 
local reaction this warns the physician that his patient is sensitized. 

To these severe symptoms the term anaphylaxis is applied. 

Some degree of protection can also be obtained by the method of 
Besredka. (See Antitoxin.) 

So far no method has been devised by which the desperate symp- 
toms of severe anaphylaxis can be cured. Adrenalin has been used 
with considerable success. The drug which would seem to promise 
the most relief, so far as the pulmonary edema is concerned, is 
atropine in full doses. Ether by inhalation has also been praised. 

Notwithstanding the startling effects in these cases, it is to be dis- 
% tinctly understood and sharply emphasized that the number of these 
accidents has been so infinitesimal as compared to the hundreds of 
thousands of injections given during the last ten years, that no hesi- 
tation should be tolerated in the use of antitoxin in diphtheria except 
in the class of cases already referred to and under the conditions about 
to be named, for the danger of the disease is great and that of the 
injection is so small as to be negligible. Thus, in 100,000 cases, 
reported by Park, in which immunizing doses were given, only 1 death 
occurred and that was a child who had status lymphaticus. 

An important fact to be borne in mind is that the injection of horse 
serum at any previous time in the patient's life may have produced 
sensitization, thereby producing a state in which the severe symptoms 
already spoken of may ensue when a subsequent dose is given. This 
condition, called anaphylaxis, does not take place if the doses of serum 
are given every few hours or even every other day for an indefinite 
period of time. It is only when a longer interval elapses between 
doses, amounting to seven days or more, that the patient is in danger 
of anaphylaxis when an injection is given. In other words, a patient 
who has received an immunizing dose of antitoxin, or a curative dose, 
is far more likely to develop evil symptoms after a dose given some 
time later than a patient who receives the antitoxin for the first time 
or in daily doses. 

The lesson to be learned from this in practical medicine is that 
when a patient gives a history that any antitoxin has been pre- 



756 DISEASES 

viously used, the physician should be cautious in the administration 
of the remedy. When a second attack of diphtheria is actually 
present, the danger to life is certainly far greater from the disease 
than from the possible development of anaphylaxis, but the fact that 
hypersensitiveness to antitoxic serum may have been developed by a 
previous injection must be carefully considered when the question of 
giving a dose for immunization arises. The rule would seem to be 
that where a child is thoroughly exposed to infection, an immunizing 
dose had better be given, but where the exposure is not so great as 
to lead the physician to the belief that infection is almost certain to 
occur, it may be well to avoid the use of a second immunizing dose 
for the reasons given, relying on the Schick test to determine if the 
patient is sensitized to horse serum. 

The use of the so-called Schick test will determine the course the 
physician should pursue, since it indicates those children which are 
susceptible to diphtheria and those that are practically immune. 
This test consists in injecting into the skin of the forearm, not under 
it, about 5V part of the so-called minimum lethal dose of diphtheria 
toxin for a 250-gram guinea-pig. This is diluted before injection, 
with 3 minims (0.2) of salt solution. If the patient's blood con- 
tains 3V of a un it of antitoxin in each cubic centimeter, the child is 
immune and no effect is produced, but if it needs antitoxin to arti- 
ficially protect it a reddened and tumified area develops in from 
twenty-four to forty-eight hours and lasts from sever^ to ten days, and 
then becomes brownish and scaly. A pseudo-reaction consists in 
greater infiltration, is less sharply outlined and disappears in twenty- 
four to forty-eight hours. It does not scale. The method is perfectly 
safe and the toxin ready for the test can be obtained on the market in 
capillary tubes of toxin with a tube of salt solution. 

Great care as to the prevention of the disease is needed. All cases 
should be carefully isolated; children who have been exposed should 
be quarantined for fourteen days ; persons in perfect health who have 
been nursing such patients should also be quarantined, for in the 
secretions of the throat diphtheria bacilli may be carried by an appar- 
ently healthy nurse to another patient. The nurse and physician 
should therefore gargle with saline solutions and follow this by anti- 
septic mouth washes (see Iodine and Hydrogen Peroxide), using the 
greatest cleanliness as to the hair, hands, face, and clothing. 

The maintenance of the patient's strength during an attack of 
diphtheria is of great importance. Simple, easily swallowed, and 
easily digested food should be freely given, and plenty of water 
provided to allay thirst and flush the kidneys of poisons. Milk, 
predigested or plain, is useful, as is also properly made beef-tea (see 
Feeding the Sick); soft eggs, etc., are to be given; and if swallowing 
is difficult because of soreness or paralysis, then we must feed by the 
use of the soft-rubber nasal tube, inserted through the nasal cavities 
into the pharynx after being well oiled with albolene. (See Gavage, 



DROPSY 757 

Part III.) Such a method of feeding may be resorted to in cases 
of inability to swallow arising from paralysis and consequent regurgi- 
tation; in coughing which prevents swallowing, as in tracheotomy 
cases; and in the vomiting which sometimes follows swallowing, but 
often does not follow nasal feeding. It is best to make any needful 
applications to the throat before giving the food, in order to avoid 
vomiting. 

Feeding by the rectum may also be resorted to, and hypodermo- 
clysis is not to be forgotten for the purpose of supplying fluid to the 
tissues. 

Tincture of the chloride of iron, quinine, and strychnine are of 
service to keep the kidneys active, to stimulate the heart and respira- 
tion, and to support the vital forces. The dose of the tincture of iron 
may be as much as 2 minims (0.1) every three hours, well diluted with 
water, to a child of four years. 

Steam set free in the air of the room is very useful as an adjuvant to 
local treatment, and the bronchitis-tent may be used in laryngeal 
cases. 

When the glands of the neck threaten to suppurate, ice-bags should 
be applied to the throat and pieces of ice held constantly in the mouth, 
while antitoxin is pushed in as full amounts as possible. 

If suffocation is imminent, inhalations of oxygen are to be used and 
atropine or strychnine employed, and intubation or tracheotomy may 
be resorted to. 

During convalescence the patient should be kept at absolute rest in 
bed to avoid heart failure. 

Chlorate of potassium has been used purely empirically in the treat- 
ment of this disease, but it should never be given internally, as the 
kidneys are already overburdened, and this drug is not only useless 
when so given, but is in addition a renal irritant. Although the author 
has been criticized for this last statement, he is convinced of its truth. 
It tends to disorder the stomach and exercises no useful function 
whatever. 

DROPSY. 

Dropsy is to be regarded as a symptom (not as a disease in itself) 
which may arise from many causes, such as cardiac, pulmonary, or 
renal diseases, or it may depend upon obstruction, from various causes, 
to the normal flow of the blood and lymph through the vessels and 
tissues. Its existence is dependent upon so many causes of a still 
more indirect nature that it is almost impossible to notice all of them, 
but the following consideration of the subject will at least make clear 
some of the reasons for its occurrence and indicate the means which 
are to be taken for its relief. 

At the very start we are confronted by facts which seem para- 
doxical, but which are in reality quite reconcilable. These are, that 
low arterial pressure predisposes to dropsy, and that high venous 



758 DISEASES 

pressure does likewise, or, in other words, that the cause of exudation 
on one side of the circulation is its prevention on the other. 

The explanation of these statements lies in a thorough under- 
standing of the physics of the circulatory system and its physiological 
function. It will be remembered that dropsical exudation takes 
place from the capillaries, and that the integrity of the walls of the 
bloodvessels and lymphatics depends upon normal nutrition, or, in 
other words, upon a proper blood-supply. As a consequence, dropsy 
may be due to poorly nourished vessels as much as to any other cause. 
The force exercised upon the column of blood as it is driven out 
by the heart into the aorta may be considered as the chief support 
of the capillary circulation, so that if the heart be weak the pres- 
sure falls in the arteries, and in consequence the rapidity of flow is 
decreased in the capillaries, while, on the other hand, an increased 
cardiac activity hastens the capillary circulation. As the arterial 
pressure and force depend not only upon the heart force, but also 
upon the tonicity of the arteries which carry the blood-stream, it 
becomes evident that dilated arteries must lower blood-pressure even 
if the heart be strong, although practically the heart and vasomotor 
system generally fail or increase in tone together. We find, there- 
fore, that a weak heart or a relaxed artery tends to cause stagnation 
of the blood in the capillaries, and, having found that such stagnation 
tends to produce exudation, it is not difficult to understand why low 
arterial pressure aids in the development of dropsy. 

Having shown this to be true, let us turn to an explanation of the 
fact that a high pressure in the veins is productive of the same changes. 
Here the normal pressure is almost nothing, being much less than 
in the arteries, and considerably less than in the capillaries. The 
result of this is, that in health the blood flows rapidly from the high 
pressure of the artery to the low pressure of the vein, and passes 
through the small veins under a gradually decreasing pressure until 
it reaches the heart. Any obstruction to this venous flow must 
increase the venous pressure, and, the venous pressure being increased, 
the rapidity of flow through the capillaries must be decreased. The 
whole subject may be made more clear by the following example: 

Suppose that two iron tubes are connected at the ends by several 
lines of rubber tubes (the capillaries), and that water is flowing into 
the first tube, or the artery, under a pressure which is represented 
by the figure 100, while the resistance to the flow in the second tube, 
the vein, is represented by the figure 0. It at once becomes evident 
that the rapidity of the flow through the connecting rubber tubes will 
be very great, whereas if the pressure in the first or arterial tube is 
decreased to 50, the rapidity is decreased to one-half, or if the pres- 
sure in the second tube be increased to 50 instead of remaining at 0, 
the same change will occur; in either instance capillary flow is lessened 
and exudation is caused. This is a crude explanation of what may 
be called the mechanical pathology of dropsy. 



DROPSY 759 

In cardiac disease dropsy is due to. a weak heart being unable to 
supply the arteries with enough blood to maintain the normal press- 
ure, or to a damming-up of blood in the venous system as the result 
of the imperfect emptying of the cardiac cavities. In the first 
instance low arterial pressure produces dropsy; in the second, high 
venous pressure has a similar effect. 1 

In renal troubles the dropsy depends more upon the lack of proper 
nutritive processes in the capillary walls and upon changes in the 
blood and blood-pressure than upon other causes. If the kidney is 
diseased, it may not be able to eliminate the proper quantity of 
liquids, which accumulate and finally escape into the tissues, while 
the same failure in renal function causes disease of the bloodvessels 
themselves, and often produces cardiac complications. 

Hepatic troubles cause dropsy by producing pressure upon the 
large bloodvessels going to the liver, and, in consequence, the exu- 
date is generally confined to the lower limbs and abdomen. If the 
hepatic trouble be severe, some failure in the nutrition of the blood- 
vessels and changes in the quality of the blood may ensue. 

Pulmonary disease rarely causes dropsy unless the venous pres- 
sure is greatly increased and is productive of cardiac dilatation, or, 
as in phthisis, where the changes in the nutrition of the body involve 
the heart, the bloodvessel walls and the blood. 

Having spoken of these causes of dropsy, it remains to consider 
its treatment, which may be divided into two parts— namely, that 
directed to its removal after the liquid is poured out, and its relief 
or cure by direct attention to its causes. The means for the removal 
of the fluid are suitable to all cases, be the cause what it may, unless 
the dropsy be of renal origin. Whenever an accumulation of liquid 
takes place in the tissues, drugs or measures must be resorted to 
which will cause the emunctories of the body to get rid of it. We 
may employ elaterium in the dose of £ grain (0.01), or elaterin in 
the dose of yo grain (0.003), placed in the mouth and washed down 
by a little water, or the compound jalap powder may be resorted to 
in the dose of 20 to 30 grains (1.3-2.0), and to it may be added, to 
increase its efficiency, 15 grains (1.0) more of bitartrate of potassium 
than the official powder contains. These two remedies are particu- 
larly serviceable in renal dropsies, since the elaterium is supposed 
to aid in the elimination of urea by the bowel, while the cream of 
tartar in the jalap powder increases the action of the kidneys. 

The cream of tartar is not to be employed in cases of acute nephritis. 

Compound extract of colocynth may be employed in the dose of 
5 to 15 grains (0.3-1.0), according to the state and idiosyncrasy of 
the patient. 

All these remedies relieve dropsy by causing so great an outpour- 
ing of liquid from the bloodvessels of the intestine that the liquids- in 

1 For an explanation of these changes in the action of the muscle, valves and cardiac 
action in heart disease, see the article on Heart Disease. 



760 DISEASES 

the tissues are taken up by the depleted bloodvessels to replace the 
loss through the action of the purgative. In other words, these 
purgatives render the alkalinity of the blood greater by concentration, 
and absorption of fluid occurs by reason of the following physiological 
and physical facts: 

As is well known to every physiologist, the passage through a 
bloodvessel of a salt solution of less than 0.7 per cent, causes an 
abstraction of salts from the surrounding tissues by the circulating 
fluid, in order that the amount of salts in the vessels and tissues 
may be identical. At the same time the tissues become infiltrated 
with liquid. On the other hand, if the solution be stronger than 
the normal 0.7 per cent., the liquid leaves the tissues to enter the 
vessels, and the tissues in consequence shrink. 

When salines are given to relieve dropsy, they must be admin- 
istered in concentrated or saturated solution and on an empty 
stomach, total abstinence from the drinking of water being insisted 
upon until they have fully acted, for the reasons given in the last 
paragraph. For this reason they should be given an hour or so 
before breakfast. If these directions are not followed, this method 
of treatment is useless. (See Magnesium Sulphate.) 

The other means which we possess for the removal of dropsy are 
by way of the kidneys and skin. If the kidneys are hopelessly 
diseased, that pathway is almost useless; but if they are only pas- 
sive or partly inactive, diuretics may be used to stimulate their 
secreting structure and to increase the leakage of liquid through 
them by increasing blood-pressure. 

Closely allied to this plan is the so-called Karell method which 
consists in starvation of the patient as to both liquids and solids. 
At the start only half a glass of skimmed milk is allowed the patient 
at intervals of two hours, but not more than 800 cc is permissible. 
The milk must be sipped, not gulped, and the quantity is gradually 
increased so that at the end of two weeks the total amount of milk 
is doubled. If this is uncontrollable a very little water or coffee 
is permitted and if hunger is so great that the patient threatens 
to break the rules a small portion of bread is given. This method 
is said to be of the greatest benefit in cardio-renal dropsy, but it is 
evident that if a patient is very feeble or the heart muscle is degen- 
erated it must be attempted, if at all, with caution. It is certainly 
much too rigorous for many patients. 

It has been proved that in acute and chronic parenchymatous 
nephritis the kidneys are often unable to eliminate the daily quantity 
of chlorides which they excrete in health, and it is considered by many 
that the resulting accumulation of sodium chloride in the tissues 
requires an excess of water to be retained to maintain the normal 
molecular concentration, and that this in return results in dropsy. 
Further, it has been proved that if some of these cases are placed 
upon a diet which contains less than 45 grains (3.0) of salt a day, 



DROPSY 761 

they develop diuresis and the dropsy decreases, in some instances, 
because the tissues are no longer loaded with chlorides. As milk 
is low in chlorides this may be one of the reasons why it is useful 
as a diet in nephritis. 

Often the kidneys will be found inactive because, owing to con- 
gestion from cardiac trouble, they cannot act. Under these circum- 
stances digitalis, in 5- to 15-minim (0.3-1.0) doses of the tincture, 
given three times a day, will be of value, and its efficacy will be 
increased by the addition of 2 grains of caffeine twice or thrice a day 
in many cases. Digitalis and squill, in pill form, as follows, may be 
used: 

I^ — Pulveris digitalis gr. xx (1.3) 

Pulveris scillae gr. xx (1.3). — M. 

Fiant pilulse, No. xx. 

S. — -One every five hours. 

Or digitalis and calomel may be employed in pill form in renal 
and cardiac dropsies. 

Caffeine is a useful diuretic, particularly in torpidity of the kidneys, 
as it stimulates the secretory epithelium, thus eliminating urea and 
other effete matters, and increases the passage of liquids by the 
increased blood-pressure which it produces. 

Pituitrin, given in the dose of 15 minims (1.0) hypodermically or 
by the mouth twice a day, is often an efficient diuretic in cardiac 
dropsy. 

No drug should ever be given hypodermically in dropsy of a general 
character, as it will not be absorbed from the water-soaked tissue with 
any rapidity, if at all. 

The chief means of relief to be resorted to in cases of ascites is 
tapping. Efforts to remove effusion in the peritoneal cavity by 
medicinal measures are rarely followed by success. In reality, 
tapping is far less heroic treatment than purgation, and the old 
theory that it is dangerous has been disproved. It has been found 
that tapping not only removes the fluid, but may in certain cases 
of hepatic cirrhosis produce a permanent cure after from one to 
twenty or more operations. In performing tapping, the patient is 
to be placed in a sitting or semirecumbent position, and directed to 
evacute his bladder, so that there will be no danger of this viscus 
being injured by the trocar. The skin of the abdomen in the middle 
line one or two inches below the umbilicus is next benumbed by 
the subcutaneous injection of a few drops of a solution of eucaine or 
cocaine. The physician then takes a trocar and cannula, at least 
four inches long, and pushes it through the abdominal wall until by 
the decrease in resistance he knows the point has entered the abdom- 
inal cavity. It is well to have a broad abdominal bandage placed 
around the belly, so that an assistant by pulling on its ends may 
support the belly-walls when they become relaxed by the escape 
of the effusion. As a rule, not more than one-half or three-fourths 



762 DISEASES 

of the liquid should be removed at one sitting, as its entire removal 
may be followed by collapse or by rapid formation of fresh transudate. 

The value of iodide of potassium in cases of ascites is not to be 
forgotten, but it must be given cautiously if renal disease is present. 

Dropsical patients can sometimes be relieved of large amounts of 
fluid by elevating the head of the bed and introducing into each 
leg a cannula to which is attached a rubber tube the lower end of 
which is placed in a bottle, one of which is hung on each side of 
the bed. When this plan fails and the tenseness of the skin in the 
lower extremities causes danger of local sloughs, several free incisions 
for the escape of the liquid should be made, the limbs being encased 
in sterilized gauze to absorb the liquid. 

DYSENTERY. 

(See Diarrhea and Dysentery.) 

DYSMENORRHEA. 

The existence of dysmenorrhea depend upon so many conditions 
that the treatment employed in one case often fails to produce 
success in the next. This is not the place for a consideration of 
the surgical measures adopted for the cure of this symptom, and 
only the medical treatment will be spoken of. 

When dysmenorrhea results from the taking of a cold, and is 
accompanied by uterine congestion and irritability, the following 
measures are particularly valuable, and may do good in many cases 
depending upon other causes: The patient should take a hot sitz- 
bath, and immediately get into bed as soon as the buttocks are dried, 
being well covered, while in the tub and afterward, by a blanket. 
A turpentine stupe is now to be used (see Turpentine), and 10 grains 
(0.6) of Dover's powder to be administered unless an idiosyncrasy 
toward opium is known to exist, when a half or a fourth of this 
amount may be employed or 10 grains (0.6) of Tully's powder 
employed. Often when the attack is accompanied by constipation 
a purgative dose of Epsom salt is of service. 

If the pain is persistent and severe, a suppository of 1 grain (0.06) 
of the extract of hyoscyamus may be inserted into the rectum. 
The latter method is generally impracticable and is rarely resorted 
to. Very commonly full doses of tincture of hyoscyamus is of 
service in relaxing the spasm of the cervix and of the uterine fundus. 

Some practitioners resort to the use of opium at each epoch, and 
keep the patient partially narcotized until menstruation is passed. 
This is unjustifiable since the physician is simply dodging effective 
treatment of the trouble and predisposing the patient to future 
attacks by reason of the constipation and the resulting habit which 
is almost sure to appear after the repeated employment of opiates. 

When the dysmenorrhea is due to obstruction of the cervical canal 



DYSPNEA 763 

by organic changes or flexions, these conditions must, of course, be 
relieved before a cure can be expected, and the medical treatment 
can be directed only to alleviation of the pain. Divulsions or slow 
or rapid cervical dilatation should be carried out by the use of 
instruments. 

In neuralgic dysmenorrhea, dependent rather upon nervous dis- 
order accompanying menstruation than upon menstruation itself, 
measures directed to the improvement of the nervous system and 
the nutrition of the patient are necessary. (See Rest Cure.) These 
cases generally occur in nervous, anemic women run down by excess- 
ive dancing or other gayety or by the bearing -and care of a large 
family of children. 

A course of strychnine or quinine and iron in small doses is often 
beneficial in these cases, and horseback exercise between the men- 
strual periods, out-of-door life, and avoidance of excessive dancing 
and exhausting exercise are to be ordered. 

Cannabis and gelsemium are often of great service, both as cures 
and alleviators of the pain, and antipyrine, acetanilid, and similar 
drugs may be resorted to while the attack lasts if it be neuralgic. 

Sometimes bathing the loins, between the periods, with alternate 
dashes of hot and cold water may do good in atonic patients. In 
other cases a hot vaginal douche at the onset of pain may give 
relief. 

When the pain seems to be greater than the patient can bear, 
enough ether or chloroform should be given by the physician, by 
means of inhalation, to produce the primary stages of relaxation. 
Chloral and other drugs capable of causing a habit are to be carefully 
avoided for obvious reasons. 

DYSPEPSIA. 

(See Indigestion.) 

DYSPNEA. 

Shortness of breath, or dyspnea, arises from asthma, cardiac 
weakness, from the accumulation of fluid in the chest, from the 
involvement of the lungs by any disease process in such a way that 
respiration becomes impaired, or it is produced by indigestion, or, 
finally, by the encroachment on the lungs or chest-walls of morbid 
growths. It may also be due to uremic or diabetic toxemia. 

Each of these states must be removed to effect a cure, but it is 
only of the relief of the symptoms that we will speak. 

In old persons who suffer from dyspnea the result of bronchor- 
rhea, when a large amount of liquid fills the bronchial tubes and 
shortness of breath follows exertion, strychnine or caffeine is the 
best remedy. Its value depends upon its powerful influence over 
the respiratory centers, on which it acts as a stimulant; and as these 



764 DISEASES 

cases very commonly also have dilatation of the right side of the 
heart, with consequent cardiac enfeeblement, strychnine is of addi- 
tional service through its influence upon the circulation. These indi- 
viduals are not to be given opium or its alkaloids or any sedative drugs, 
as such medicines, while giving temporary relief from cough, only 
serve to depress the respiratory apparatus and cause an accumulation 
of liquid mucus in the chest as a result of the prevention of cough 
and expectoration. The cases in which opium, or morphine, does 
good are those in which, through nervousness or functional nervous 
disorder, the respiratory cycle is imperfect, and, above all, in those 
instances in which dyspnea occurs as the result of cardiac disease. 
In these cases the attacks of oppression and suffocation can often 
be entirely prevented by the use of J to i grain (0.008-0.015) of 
morphine, given every night or each night and morning. If these 
doses fail, larger ones may be cautiously used. Hyoscine, instead 
of causing sleep, nearly always makes these cases worse. 

Sometimes a little carbonate of ammonium is useful as a respira- 
tory and cardiac stimulant in cases of dyspnea. 

Dry cupping applied over the back of the chest may also be service- 
able when shortness of breath from cardiac or pulmonary trouble is 
present. 

In cases of dyspnea due to emphysema and pulmonary inflam- 
mation of a chronic type, or in those persons who take cold on the 
slightest exposure, particularly after attacks of asthma, arsenic is 
useful if continuously employed. 

If pleural effusion be present, relief of a positive and lasting nature 
can only be obtained through aspiration, or, in other words, by the 
operation known as paracentesis thoracis. 

EARACHE. 

Earache may arise from a great number of causes, all of which 
are, practically speaking, inflammatory. The pain may be the result 
of acute or chronic inflammation of the middle ear, with a serous 
or purulent exudate, or of furunculosis of the external auditory canal. 
In other cases an eczema of this part is very painful. 

The treatment of an acute earache is systemic and local, the 
former being based on the general rules governing the management 
of inflammatory processes, the latter according to the area involved 
and the cause of the trouble. Cardiac sedatives are indicated, but 
quinine is distinctly contraindicated, as it tends to cause aural con- 
gestion. In the general treatment several leeches may be placed in 
front of or behind the ear, and heat in a dry form is to be applied to 
the head on the side affected, by means of a hot-water bottle or 
water-bag. Poultices, oil and laudanum, and similar applications 
are not to be resorted to, as they may ultimately produce too exten- 
sive suppuration, and they do not always give even temporary relief, 



EARACHE 



765 



. . . gr. x (0.6) 

. . . gr. xij (0.8) 

. . . gr. x (0.6) 

q. s. ad f3iij (90.0).— M. 



but tincture of belladonna and tincture of opium in equal parts 
carefully warmed may be dropped in the ear in the dose of 5 to 10 
minims (0.3-0.6) when necessary. 

A very efficient means of relieving the pain is to irrigate every 
hour or two the ear by means of a fountain syringe with normal 
salt solution used as hot as can be borne (Fig. 129). 

If a cold in the head is present, and with it acute myringitis, it is 
important to establish a free opening through the nostrils, particu- 
larly if the middle ear also is involved, in order to clear the orifice 
of the Eustachian tube. This is to be accomplished by dropping 
into each nostril adrenalin chloride (1 : 5000 solution) or 1 to 3 minims 
(0.06-0.2) of a 4 per cent, solution of cocaine, and, as soon as the 
engorged mucous membrane is anesthetic and shrunken, to use the 
following solution in an atomizer with a fine spray attachment: 

1$ — Acidi borici 

Sodii chloridi 

Sodii boratis 

Aquae rosae 

S — Use as a spray. 

This should be followed by a spray of menthol and albolene, 3 grains 
to the ounce (0.2:30.0), in order that the menthol may prolong the 
effect of the cocaine and prevent 
secondary congestion. This is to 
be followed by inflation of the Eus- 
tachian tube with a Politzer air-bag. 
Only in most obstinately painful cases 
of acute middle-ear catarrh is para- 
centesis of the drum to be performed. 

Should true septic otitis media de- 
velop and drainage of the middle ear 
become impossible through blocking 
of the Eustachian tube, then the 
physician must very gently irrigate 
the external auditory canal with as 
hot water as can be borne, and 
render it aseptic by insufflations 
of boric acid powder. These irri- 
gations should be frequently prac- 
ticed, and if the pain persists and the tympanic membrane 
begins to bulge, paracentesis must be performed in the most 
bulging part of the lower quadrant. After the paracentesis needle 
is withdrawn the discharge should be allowed to flow freely. The 
canal is then to be well irrigated with hot 1 : 2000 permanganate of 
potassium or hot carbolized water (1:50), and as the discharge is 
constant a thin piece of sterilized gauze should be inserted and 
allowed to act as a drain (not as a packing) and removed as often 
as soiled. 

In a case of eczema of the ear, hot irrigation, followed by the 
application of powdered iodoform, is perhaps the best application 




Fig. 129. — Aural irrigator. 



766 DISEASES 

for temporary treatment. In furunculosis of the ear hot irrigations 
and free incision, with an iodoform dressing, are useful. 

When foreign bodies cause the pain, they are best removed by 
repeated and gentle syringing with hot water. Forceps are danger- 
ous instruments in the hands of a novice treating the ear. 

In earache due to neuralgia a small compress wet with chloroform 
may be applied to the skin in front of and behind the ear. 

ECZEMA. 

This is probably the most common form of skin disease which the 
physician is called upon to treat, with the exception of acne. 

Dermatologists divide it into many forms and stages, but in this 
'book a consideration of its forms is out of place, and only the treat- 
ment for its stages is proper. 

In the first place, it may be stated that the treatment is a quadruple 
one— namely, dietetic, hygienic, external, and internal. 

In regard to diet, the patient should be told to avoid salty foods, 
such as salted fish or pork and corned beef; greasy foods, such as 
bacon and fried dishes; pastry and cheese. At most only moderate 
amounts of wine and beer can be taken, and foods difficult of digestion 
are to be stricken off the bill of fare. 

In the way of hygienic measures, fresh air, the avoidance of seden- 
tary habits, horseback exercise or walking are to be recommended. 

External treatment is the most important of the two measures in 
which drugs are employed, and its course is perhaps best described 
by taking a case of ordinary eczema as an example and treating it 
through its entire course. 

In the early stages of an acute eczema, when the process is very 
active and the erythematous reddening is merging into the forma- 
tion of vesicles or pustules, with the formation of large scabs, no 
application is better than oxide-of-zinc ointment, thoroughly applied 
night and morning. If the eczema be situated upon the scalp, the 
hair must be invariably clipped short or shaved off in such a way 
as to prevent the gluing of the hair into a mat by reason of the 
discharge. The ointment may be smeared over the part or applied 
on a piece of lint in a thick layer. Nearly always the ointment 
should be used in conjunction with black wash (calomel 1 dram 
[4.0], lime-water 1 pint [480.0]), which should be applied twice a 
day, just before the zinc ointment is resorted to, by means of a 
swab or sop, and allowed to dry. In other cases the powdered oxide 
of zinc is dusted over the part if the discharge is very watery and 
profuse, or the following ointment, recommended by McCall Ander- 
son, is very efficacious: 

3— Bismuthi oxidi §j (30.0) 

Acidi oleici puri 5 viij (240.0) 

Cera alba? giij (90.0) 

Petrolati . §ix (270.0) 

Oleirosse TUv (0.3).— M. 

Fiat unguentum. 

S. — Apply to the part affected. . • 



ECZEMA 767 

As the quantities of this prescription are large, they may be 
reduced one-half for use in localized eczema. 

Where the proliferation of cells and the secretion are very pro- 
fuse it may become necessary to remove the crusts before the local 
remedies can reach the skin, and for this purpose poultices may be 
used; or, if the disease be on the face, the parts should be anointed 
with olive oil, containing 1 or 2 minims of phenol to the ounce (0.06- 
0.12:30.0), to soften the crusts, which are readily removed in a half- 
hour by the use of castile soap and water. The soap and water are 
not to be used if the inflammatory area is very angry looking. When- 
ever itching is an annoying factor, the parts should be protected by 
lint smeared with some simple ointment, which may be carbolized, 
both for its antiseptic and local anesthetic effect. English and 
American dermatologists use what is known as liquor carbonis 
detergens very largely in the acute stages of eczema. It should 
not be used pure, but diluted in such a way that for each 4 ounces 
(120.0) of water 2 drams (8.0) of the pure liquor are present. Liquor 
carbonis detergens is made by taking 9 ounces (270.0) of tincture 
of soap-bark (quillaja-bark) and 4 ounces (120.0) of coal-tar, mixing 
and allowing them to digest for eight days, after which the mixture 
is filtered and is then ready for use. 

In infants light splints may be put on the arms to prevent the 
child from scratching the parts, and if there is a free outpouring of 
serum the following lotion may be dabbed on the inflamed area 
every few hours: 

3— Phenolis TTlxv (1.0) 

Ichthyolis 5j (4.0) 

Zinci oxidi 3ij (8.0) 

Magnesii carbonatis 5ij (8.0) 

Liquor, calcis fgiv (120.0).— M. 

S. — Use locally. 

If crusts are present the following may be placed on a piece of 
lint in which holes are cut for the nose, eyes, and mouth, tapes 
being attached to the edges of the lint, so that it can be held on the 
child's face by tying them back of the head: 

Ifc — Acidi salicylici gr. iv (0.3) 

Ichthyolis gr. xx (1.3) 

Zinci oxidi gr. xxx (2.0) 

Unguent, aquae rosee . §ij (60.0). — M. 

When the disease has passed from the acute, active inflammation 
of the first stage to the subacute form of the second stage, applica- 
tions of a mildly stimulant character are necessary. Before this 
the aim has been to soothe the parts; now they must be excited to 
normal activity. For this purpose resorcinol in the proportion of 
2 to 30 grains to the ounce (0.12-2.0:30.0) of lard, according to 
the severity and induration of the lesion in the skin, may be used. 

Where the disease is chronic and very persistent, and sluggish or 
atonic in its course, still more powerful remedies are necessary, such 



768 DISEASES 

as salicylic acid, tar, or tincture of green soap used with hot water 
until the skin beneath is bared, dressing this by means of zinc oint- 
ment or resorcinol ointment, 2 to 10 grains to the ounce (0.12-0.6: 
30.0), spread on a cloth. The salicylic acid should be used in the 
proportion of 30 to 60 grains to the ounce (2.0^.0:30.0) of lard, 
while the tar is used in the form of the pure official tar ointment. 

1$ — Unguenti picis liquidi 5j (4.0) 

Unguenti zinci oxidi 5vij (28.0). — M. 

S. — ■ Apply to the parts. 

In seborrheic eczema, where the secretion is greasy and dry, and 
"complicated, if wrongly treated, by oozing and the pouring out of 
serum and the formation of cells which form crusts, the following 
prescription is of value: 

1$ — Resorcinolis gr. x vel xx (0.6-1.3) 

Pulvis amyli, 

Unguenti zinci oxidi ' . aa 3ij (8.0) 

Petrolati 5ss (16.0).— M. 

Sig. — To be applied after removing the scabs by the use of a lotion composed of 
1 part of bay rum and 3 parts of water. 

The internal treatment is directed to the cure of any disordered 
function which is present, such as dyspepsia (see Indigestion) , hepatic 
torpor, general debility, anemia, scrofulosis, inanition, constipation, 
gouty diathesis, or renal insufficiency. The gastric disorder is to 
be relieved by the use of hydrochloric acid and pepsin; the hepatic 
torpor by mercury, podophyllin, or, better still, by freshly pre- 
pared strong nitrohydrochloric acid added to water; the debility by 
tonics, such as cinchona, cod-liver oil, strychnine, and bitters; the 
anemia by iron, and, if scrofulosis exists, by the syrup of the iodide 
of iron. Constipation is to be cured by the use of proper foods and 
laxatives, and the gouty tendency counteracted by the employment 
of the salicylates, lithium citrate, colchicum, or potassium iodide. 
If the kidneys are at fault because of torpidity, the diuretic potas- 
sium salts, such as the citrate, are indicated. Arsenic is never to 
be used, except in those instances where the skin is very dry, and 
where, by improving digestion and through its alterative power, it 
may do good. In the chronic forms of dry eczema or those depend- 
ing upon an atonic state of the trophic nerves of the skin, arsenic is 
of great value in the form of Fowler's solution, or arsenic trioxide 
may be given. 

EMISSIONS. 

Seminal emissions occur as the result of sexual abuse, whereby a 
condition of hyperexcitation of the nerve cells in the spinal cord 
and the nerves of the genitalia is developed, or they are due to 
peripheral or centric irritations, which reflexly irritate the genitalia or 
their nerves, and to a number of other similar causes. These emis- 
sions also occur with some periodicity in normal males who are 



EMPYEMA 769 

continent and chaste, and under these circumstances are not to be 
interfered with by treatment unless the emissions become excessive. 

The former types are, however, proper for medical treatment, 
and their cure consists in the avoidance of unchaste literature and 
lascivious thoughts during the waking hours, and the use of such 
spinal and cerebral sedatives that the centers governing the ejacu- 
lations of semen may be calmed, and so quiet a sleep produced that 
erotic dreams are avoided. The patient should sleep on a hard 
hair mattress, not be too heavily covered, and should avoid sleeping 
on his back, as this causes an undue blood supply to -the spinal 
centers, and consequent stimulation and ejaculations. Sometimes 
hard bodies, such as spools, are tied around the loins, so that lying 
on the back will cause so much discomfort that the patient awakes 
and turns on his side. The drugs to be used are bromide of potas- 
sium or sodium in 20-grain (1.3) doses at bedtime, or chloral may 
be taken in the same amount. Hyoscine is certainly of value in 
the dose of y^u grain (0.0006). Sometimes a warm sitz-bath or 
general bath before going to bed is of service. In other cases, where 
atony is the cause of the trouble, the physician should recommend 
cold sponging of the perineum and loins night and morning. 

In the cases in which emissions come on as the result of conti- 
nence, and become excessive, the remedies just named are to be 
tried, but do not effect any permanent cure unless used until sexual 
power is seriously depressed, so that it has been the custom of 
many physicians to recommend "marriage," which the patient may 
interpret in its legitimate light or not as he pleases. 

It is worthy of note that all irritations of the urinary bladder and 
other parts of the genitourinary system should be removed, and it 
is often of value to administer citrate of potassium in 20-grain (1.3) 
doses, in water, three times a day, to render the urine non-irritating 
and alkaline. Stimulating foods and drinks are to be interdicted, 
and condiments, such as pepper and mustard, avoided. 

Sometimes, when the emissions are caused by genital atony, strych- 
nine and arsenic are of great service if given in full dose. 

In many of these cases it is the duty of the physician to treat 
the moral state of his patient as well as to give medicines. Many 
persons, believing that emissions are always an evidence of disease, 
read books on such subjects which are sold by quacks, and soon 
find their way to the hands of these persons. A few sensibly consult 
a regular physician. Half the treatment in these instances consists 
in assurring the patient that he has nothing to worry about, and in 
making him feel that the physician is his friend and worthy of all 
confidence and complete belief. 

EMPYEMA. 

(See Pleuritis.) 
49 



DISEASES 



ENDOCARDITIS. 



Endocarditis may be acute or chronic. Acute endocarditis occurs 
as a result of some general infection which is usually rheumatism. 

In acute sthenic endocarditis tincture of aconite, 10 minims (0.65) 
given every hour until the physiological symptoms of its influence 
are present, is useful, or with equal efficacy may be employed the 
tincture of veratrum (10 to 15 minims [0.6-1.0]). In most cases 
it is better to apply an ice-bag over the heart. Aconite and other 
depressants are contraindicated if the heart is at all feeble, and 
should only be used in the earliest stages of the disease. The most 
important measure is absolute rest upon the back. This must be 
insisted upon. If the cause of the disease is acute rheumatism, a 
number of small blisters placed on the precordium will be of value 
in preventing pericardial complications. (See Acute Rheumatism.) 
If the disease becomes ulcerative, supporting treatment, consisting 
chiefly in the use of good food and the free administration of the 
tincture of the chloride of iron, should be resorted to. (See Vaccines.) 

EPILEPSY. 

The disease known as epilepsy is probably the most disheartening 
condition as to treatment that the physician has to deal with, since 
it often resists the influences of all the standard remedies, and drives 
the practitioner from drug to drug in the hope of finding one which 
will be at least alleviating in its effects. For this reason the author 
has in this article included many of the drugs which are rarely used, 
as well as those generally recognized as useful in its treatment, in 
order that the physician may try every remedy of any possible value. 
In the treatment of epilepsy the fact must be borne in mind that the 
convulsions are the result of a lack of nervous control or balance. 
In idiopathic epilepsy there exists a state of impaired nervous equi- 
librium, with the result that explosions of nervous energy take place 
from the motor cortex of the cerebrum. These cases almost always 
develop in childhood and are dependent upon a congenital defect. 
A careful examination of them will nearly always reveal signs of 
their not being perfectly balanced mentally and physically. At the 
same time epilepsy is not a disease of idiots by any means. Often 
sufferers from it are remarkably clever, at least for many years. 
It is evident that in cases such as these the physician cannot hope 
to cure the patient permanently, although by proper feeding, hygienic 
measures, and suitable drugs and tonics he may diminish the attacks 
very greatly. So, too, by removing causes of peripheral irritation 
he may diminish the frequency of the attacks, but he cannot eradi- 
cate the underlying nervous instability. If the condition arises 
in adult life, it is in the great majority of cases due to syphilis, to 
brain tumor, or to injuries of the skull. Under these conditions 



EPILEPSY % 771 

the prognosis "and therapeutic possibilities are better than in the 
type just described; but if the fits have lasted for any length of time, 
so that a state of instability of the cerebral cells has been established, 
the condition may be irreparable, even if the treatment be most 
skilful. 

So far as drugs are concerned, the most valuable remedy hitherto 
in use for the relief of epilepsy has been bromide of sodium, although 
such excellent results have been obtained by the use of luminal 
that it bids fair to take first place. The dose, 1J to 3 grains (0.18) at 
bedtime, and this may be fortified by 20 grains (1.3) of sodium bromide 
given three times a day. When luminal sodium is used the dose is 
2 grains (0.12), which may be increased to 5 grains (0.3). 

Bromide of sodium is not a specific, but many cases prove that 
the remedy gives relief when it is used in a suitable manner, and in 
a large number of instances the seizures are so decreased both in 
violence and frequency that its use may be said to be indicated in 
almost every case of the disease at some period in its course. In a 
very small minority, however, it signally fails. 

The doses to be used vary to a considerable extent with the salt 
employed, and depend upon the character of the disease and the 
temperament and physique of the patient. The greater the dura- 
tion of the disease, the greater is the difficulty in effecting relief, 
and the length of time during which the patient has been epileptic 
should therefore be most carefully reckoned before the treatment 
begins. Further than this, the frequency and severity of the attacks 
are to be looked into, and these points are really more important 
than the actual duration of the ailment; since if a man has only 
one fit every six months for twenty years his condition is far less 
serious than if he has a history of three or four fits a day for one 
year. Again, the character of the attack, as to its violence, may 
be the most important fact to be regarded, for if it is violent enough 
to endanger life, remedies must be pushed even beyond the point 
of tolerance. The writer once heard a celebrated physician cause 
much amusement among his auditors by detailing an instance of an 
epileptic who w T as getting well, and would have recovered if he had 
not died. His explanation was, that the man was syphilitic, and 
was receiving moderate doses of iodide and bromide of potassium, 
which were slowly benefiting him, and would have cured him had 
not a single severe fit produced death in the meanwhile. 

Another point to be considered is the condition of the digestion, 
which the bromide of potassium is peculiarly liable to disorder, and 
which is sometimes so disturbed as to necessitate the administra- 
tion of the drug by the rectum in serious cases. Females generally 
require smaller doses than males, and children of both sexes do not 
require as large quantities as adults. The dose to be used in the 
beginning of the treatment in moderate case is but 10 grains (0.6) 
thrice a day; and while this may seem a very small quantity, it will 



772 DISEASES 

be found that it can be rapidly increased in amount without causing 
the gastric distress produced by the sudden use of larger doses. 
Each day an additional 10 grains may be added, until at the end of 
a week the patient is taking 80 grains (5.3) in each twenty-four 
hours. There are very few cases which will not become saturated 
with the drug if this is done, and there are very few in which a more 
rapid arrival at bromism is needed. If, however, the patient has 
become able to stand large amounts by the prolonged use of the 
drug, the amount given is not to be governed by grains, but by 
physiological effects, and it may be pushed to any amount which 
is borne without distress. 

Full doses of the bromides, particularly in epileptics of an advanced 
type, sometimes cause maniacal outbursts in place of the epileptic 
attacks. In other instances the patients become morose and homi- 
cidal. (See article by author in Therapeutic Gazette, June, 1897.) 
Cases are on record in which the persistent use of larger doses of 
the bromides has resulted in bronchitis with profuse and dangerous 
exudation, causing suffocative bronchitis. 

There is one more point to which attention must be called, and 
that is the fact that when the bromides are taken for any length of 
time they produce bromism, which in its moderate or severe forms 
produces a mental condition closely allied to that seen in old, chronic 
epileptics. This condition of the mind should never be overlooked, 
and the ordinary mental changes of epilepsy are greatly aggravated 
by its constant and careless administration. (See Bromide of 
Potassium.) 

Many European physicians have endeavored to aid the rapid 
saturation of patients by the bromides by depriving them of common 
salt, thereby causing the salt-starved system to absorb greedily the 
bromide of sodium. It is doubtful if this plan is justifiable. 

In chronic epilepsy, with regularly recurring fits, the greatest 
good is obtained by pushing the drug in ascending doses for one 
week, and then for the succeeding week only enough is given to pre- 
serve the general effects of the medicament. By doing this the 
stomach gets a rest and the appetite is not greatly interfered with. 
For obvious reasons where the attacks occur only every two weeks 
this is a particularly useful method. 

As regards the time of day when the drug is to be taken, there 
can be no doubt. Some writers have directed that it shall always 
be taken before meals, but this is entirely lacking in advantage and 
decidedly fruitful of harm. Drugs which are given with the object 
of affecting the general system should be taken after meals, not 
before, and it is only when a local gastric effect is desired that they 
should be given on an empty stomach, particularly when the sub- 
stance is so depressing as a salt of potassium. If taken after meals, 
the appetite is not decreased, but there are few who can take a dose 
of 10 or 20 grains (0.6-1.3) of bromide of potassium before breakfast 
without suffering from indigestion. 



EPILEPSY 773 

If the attacks have a distinct periodicity, which is rare, or can 
be foretold for as long as two hours beforehand, the remedy may be 
taken in a large dose only at this time, and but a few grains given in 
the intervals; and if the attacks are severe, the physician should not 
hesitate to use large doses by the mouth and by the rectum on the 
day of the attack. 

It has been held by some that the drug should be taken in minute 
doses, frequently repeated, in order to keep the patient constantly 
under its influence. This is an example of therapeutic ignorance, 
because the bromides are slowly eliminated, and this frequent 
administration possesses the disadvantages of being inconvenient, 
annoying, and apt to disorder the stomach. 

A very important point to be borne in mind is that the drug 
often seems to have produced almost a cure, and this results in care- 
lessness in the regularity of administration. The patient should be 
impressed by the fact that every day passed without a fit is a step 
forward, and that every fit carries him many steps backward. He 
should also be directed to use the drug, in moderation, for at least 
three years after all fits have ceased, and to watch after that time 
for the slightest sign of their return. The quantity taken each day 
should be gradually decreased, not suddenly stopped. 

Before passing on to the discussion of the employment of the 
other bromides, and the conditions produced by the excessive dosage 
of all of them, we may place our use of these compounds in epilepsy 
on a scientific footing. It is now generally recognized that the 
seizures known as epilepsy arise from the cells in the cerebral cortex, 
and there can be no doubt that the bromides act very powerfully 
upon the cerebrum in the higher animals, decreasing the irritability 
of the motor centers in these regions to a very great extent. Not 
only is this pointed to by clinical facts, but the researches of Alber- 
toni prove beyond all doubt that such is their action. This investi- 
gator found that the administration of a single dose of the bromide 
of potassium so lessened the excitability of the motor cells in the 
cortex cerebri that much stronger stimulation was necessary in 
order to cause response in the limbs than was normal, and that it 
was difficult to produce epileptic attacks by means of electrical 
stimulation of the motor areas even when currents were used very 
much stronger than those which commonly produce such a result. 
He also found that this lessened irritability was increased still further 
if the drug was given for several days beforehand in such doses as 
thoroughly to impress the organism. It is therefore evident that the 
bromides act directly on the cortical areas, calming the tendency to 
explosions of nerve-force. 

The bromides of gold, iron, lithium, nickel, and ammonium have 
all been used in epilepsy with good results, but, except in certain 
instances, they fail to act as well as those of strontium, sodium, 
and potassium, unless given in large doses. Bromide of sodium and 



774 DISEASES 

of strontium are not by any means so apt to disorder the stomach, 
and are preferable in most cases on this account. They possess no 
other advantage. 

The bromide of ammonium is quite irritant and disorders the 
stomach very readily. It ought always to be used, when used at 
all, with other salts, the ammonium salt acting only as an adjuvant. 

Several clinicians have tried hydrobromic acid, but it is very much 
more apt to derange digestion and to produce vomiting than any 
of the salts. The dose of the dilute acid is \ to 3 drams (2.0-12.0) 
in a tumblerful of sweetened water. 

There can be no doubt that in some instances what is known as 
the mixed treatment is very useful. This consists most commonly 
of a prescription in which the bromides of potassium, sodium, and 
ammonium take part. Why this combination acts better than 
any one of the salts alone is unknown, but it is certainly a clinical 
fact. 

Bechterew has recommended the joint use of the bromides with 
adonis vernalis in epilepsy as follows: 

1$ — Potassii bromidi 5iij (12.0) 

Infusi adonis vernalis f^iv (120.0) 

Aquae destillatse q. s. f5vj (180.0).— M. 

S. — A dessertspoonful three times a day. 

Sometimes codeine is combined with this prescription. 

It has been claimed by Flechsig that the use of opium for a long 
period of time is useful in the treatment of epilepsy. He gives 
the opium in ascending doses during a period of six weeks, begin- 
ning with J grain (0.015) three times a day, and going as high as 
5 grains (0.3) three times a day. This method decreases the fre- 
quency and severity of the fits for several months in some cases, 
but does not cause a cure. It succeeds best in old cases and is not 
useful in recent ones. 

In still other cases digitalis, when used along with one of the 
bromides, seems to produce favorable results. Indeed, digitalis 
has for years been used alone in epilepsy with fairly good results, 
and should always be used in obstinate cases. In petit mal, in which 
bromide of potassium when used alone so often fails, it is useful, and 
several English writers, notably Gowers, assert that its best effects 
are seen in cases of nocturnal epilepsy. Why this is the case no 
one knows, and it would seem doubtful whether it is more beneficial 
in nocturnal attacks than in others. 

Another combination very much employed and lauded is bromide 
of potassium with belladonna, the mydriatic being almost useless 
alone, although of great antiquity in its use in epilepsy. Like the 
mixture of digitalis and bromide, it succeeds very frequently in 
petit mal, and, indeed, seems to be much more successful than the 
digitalis, but its mode of action is exceedingly doubtful. As the 
drug acts even more powerfully upon the nervous system than upon 



EPILEPSY 775 

the circulatory apparatus, it has been thought that its influence for 
good depended upon this effect, but the experiments of Seppilli 
contradict this belief, for he found that if atropine was given to 
an animal the surface of the cortex cerebri responded more readily 
than is normal to electrical stimulation. At one time it was held 
that belladonna acted on the spinal cord and peripheral nerves under 
such circumstances, but it should be remembered that we now know 
that atropine is only of value in relaxing spasm when given in full 
dose, oftentimes hypodermically, and that Albertoni has made a 
series of experiments to determine whether it irritates the motor 
centers of the cortex. In his hands repeated small doses or one large 
dose in no way retarded the convulsions commonly produced by 
stimulation of the brain. Both these investigators are therefore 
in accord. Under these circumstances it affects rather the motor 
nerve-endings than the central nervous apparatus. 

Nitrate of silver was brought into use long before the value of 
more recent drugs was known. Every one is agreed that it is with- 
out power for good. As the drug is eliminated very slowly, it 
rapidly accumulates in the body, and argyria soon comes on. It 
may be used, after all else fails, in doses of | to J grain (0.01-0.15) 
thrice a day after meals, the mucous membrane of the inside of the 
lips and the conjunctiva being carefully watched for the early signs 
of chronic silver-poisoning. We certainly have no knowledge as to 
its influence on the nervous system; and if it acts at all, it must be 
by some alterative influence rather than by any other means. 

Nitroglycerin is to be employed in the treatment of petit mal, 
rather than haut mal, in the dose of 1 minim (0.06) of a 1 per cent, 
solution, once, twice, or three times a day. Our knowledge of its 
effects, so far as its curative influences are concerned, is very slight, 
but it seems to benefit some cases. Its action is fleeting, and it 
influences the brain but slightly, except it be taken just before an 
attack is expected or when the cardiac action is defective. 

The use of the nitrite of amyl is not for the purpose of directly 
curing the disease, but of warding off impending attacks, the warn- 
ing of which is given by an aura of slow progression. It increases 
the severity of petit vial, but in epileptics who have a prolonged 
aura, nitrite of amyl pearls, which are small glass beads containing 
a few drops of the drug, may be used. As the aura comes on the 
patient should break one of these in a handkerchief and inhale the 
drug, thereby putting aside the attack. The influence which the 
drug exerts upon the brain is secondary rather than primary, and 
is probably dependent on its action on the blood or circulation. 
Its influence on the spinal cord and nerves is much more marked 
and direct, and it is most certainly a very powerful spinal depressant. 
Nitrite of amyl puts aside an^attack by a sudden shock to the nerve- 
centers, which diverts them, so to speak, from their intended dis- 



776 DISEASES 

charge, very much as a ligature around the arm stops an aura. 
When we remember that the drug acts instantly and converts much 
of the oxygenating blood of the body into a non-oxygen-carrying 
fluid by reason of the methemoglobin produced, the sudden change 
in the cerebral nutrition and state is easily understood. 

In the treatment of the "status epilepticus" nitrite of amyl is of 
great value in checking the seizures, and may be used under these 
circumstances in heroic amounts, applied to the nostrils at intervals. 
During the presence of the tonic spasm, if it be severe enough to 
suspend respiration, it should be remembered that if the drug is not 
inhaled it is worthless. It is only when respiration is being car- 
ried on that it can enter the lungs and do its work. The nitrite of 
potassium or of sodium or nitroglycerin should be used internally to 
supplement the nitrite of amyl. Another valued method in treating 
the status epilepticus is free bloodletting. 

The use of anesthetics during an attack of epilepsy is virtually 
useless, and in some cases dangerous, for ether is too slow in its 
effects, and may, by its irritant vapors, increase the tendency to 
laryngeal spasm or cause lung complications. Further than this, 
if uremia is the cause of the fit— and this fact is unknown in every 
case when it is seen for the first time until the individual is carefully 
examined— the ether may further irritate the kidneys. 

Chloroform, though it acts much more rapidly, may cause sudden 
cardiac failure, and both drugs may increase the post-convulsive 
coma very greatly. In status epilepticus they may be used, as in 
such case the convulsions must be stopped at all hazards, but the 
preference should be always for amyl nitrite, which may be given 
hypodermically. 

The iodide of potassium is useless in epilepsy unless the disease 
is due to syphilis, when it is of the greatest service. Indeed, the 
bromide and all other drugs but mercury should be discarded while 
these are pushed to the utmost. As is well known, syphilitics usually 
bear iodides extremely well, and the author knows of one instance 
in which no less than 800 grains (53.0) were taken every twenty- 
four hours, with rapid improvement as a result. This point is 
strongly insisted upon by all therapeutists and syphilographers, 
notably Fournier. 

Where the convulsions are due to the presence of a gumma, how- 
ever, the iodide of potassium is too slow in its action, and mercury 
should be depended upon in order to break down the growth with- 
out delay, lest a seizure cause death by glottic closure, producing 
asphyxia or some similar accident. 

Chloral possesses the disadvantages, as compared with the bro- 
mides, of being a very fatal poison, which is an important fact to 
be borne in mind by the physician when giving it to a patient whose 
mind is already weakened by the disease or who is naturally stupid, 



EPILEPSY 777 

and who may forget the dose and take too much. Its physiological 
action indicates much more fully that it may be of value than does 
that of many other more lauded remedies, since it exerts its chief 
influence on the motor pathways of the spinal cord and quiets the 
intellectual portion of the cerebral cortex, and so produces sleep. 
Seppilli has proved this by direct experimentation after the method 
employed by Albertoni. Its use, combined with one of the bromides, 
is often followed by the most desirable results, and it should be tried 
at all times unless some cardiac complication forbids it. It may 
disorder the stomach, and should, like the bromides, always be given 
well diluted and after meals. 

Of the more recent remedies, acetanilid stands in the foremost 
rank, and bids fair in some instances to rival the bromides. German- 
See, the author, and some others have reported cases which obtained 
marked relief from it, and more recent investigators have done 
likewise. The drug will be found to exert its beneficial effect chiefly 
in chronic epilepsy. 

Antipyrine has been recommended by Lemoine'in certain forms 
of epilepsy, but it has been condemned by other clinicians. He 
found it very useful in cases associated with migraine. In these 
cases the results were better than with the bromides, but in the 
idiopathic simple varieties it was useless. Mairet and Combemale 
have used the drug in epileptiform mania with satisfactory results. 

In the epilepsy of childhood Solanum Carolinense in the form of 
the fluidextract, in the dose of 2 to 15 minims (0.1-1.0 cc), is 
sometimes a useful drug. 

The value of the treatment of epilepsy by borax has not received 
very wide recognition. Perhaps the most thorough studies of its 
effects have been those of Gowers in England and Folsom in America. 
It would seem that some cases which are obstinate under ordinary 
treatment are benefited by borax, but it is certainly not to be com- 
monlv employed. The dose generally given is about 15 grains 
(1.0). (See Borax.) 

A very important point, which is constantly brought before the 
physician who is treating epilepsy, is that of diet. Nearly every 
patient who suffers from this disease inquires what he shall eat. 
Few researches of a thorough character have been carried out on 
a large scale to determine what may or may not be ingested. Curi- 
ously enough, the influence of diet in one research covering a number 
of cases of chronic epilepsy seemed to be of little moment. Thus, 
Merson examined 24 such cases, putting 12 of them on a purely 
vegetable, and 12 on a purely nitrogenous, diet. The result, after 
this study had been continued for two months, w T as that the vege- 
tarians had had a few less fits than the others, but the difference was 
so slight as to be of almost no weight in determining the question. 
The view that meats in moderate amounts are harmful is erroneous. 



778 DISEASES 



EPISCLERITIS. 

Episcleritis occurs in the form of reddish, sometimes violaceous, 
subconjunctival swellings, nodes or patches, which usually appear in 
the ciliary region on the temporal side, though they may develop in 
any portion of the zone. To severe types of this disease, in the 
form of diffuse, bluish-red injection, often associated with crescentic 
areas of infiltration in the cornea and involvement of the iris and 
ciliary body, the term scleritis is applied. These lesions appear to 
be due to gout, tuberculosis, menstrual derangements, enterogenous 
auto-intoxication and focal infections in the buccal mucous mem- 
brane, sinuses and tonsils; rarely syphilis. Hence the treatment 
requires ample general and local examination in order to discover 
and eliminate the cause. Internally the salicylates, aspirin and 
sometimes mercury and the iodides are useful, the medicinal and 
dietetic treatment being determined by the etiologic factor. Locally, 
atropine mydriasis is important, especially in the severe types, and 
hot compresses and dionin (5 per cent.) to relieve pain. Occasionally, 
eserine sulphate and pilocarpine hydrochloride (f-| grain [0.0162- 
0.324 gm.]) to the ounce (30 cc) are required, if iritis is not a com- 
plicating feature and there is a tendency to rise of intraocular pres- 
sure. In the presence of a tuberculous taint injections of tuberculin 
are of service. In chronic types massage with the yellow oxide of 
mercury ointment (gr. j~3j) is indicated and scarification or cauter- 
ization of the nodes have been recommended. Subconjunctival 
injections of physiologic salt solution are occasionally useful. 

Episcleritis and scleritis are prone to relapse and the danger of 
involvement of the cornea and uveal tract is always present; hence 
the need of thorough study of all conditions, local and general. 

EPISTAXIS. 

Nose-bleed depends upon many causes, the chief of which are 
traumatisms, plethora, and the presence of ulcerations in the nasal 
chambers. It also occurs as one of the prodromata of typhoid 
fever and in some cases of cardiac valvular disease. 

The measures to be adopted for. its control are both medicinal and 
non-medicinal. If the individual is full-blooded and strong, full 
doses of tincture of aconite or veratrum are useful, say 5 to 10 
minims (0.3-0.6) of one of them, followed in a half -hour by a smaller 
dose, if necessary. The value of these drugs depends upon their 
power of lowering blood-pressure, and in consequence decreasing 
the leakage from the break in the wall of the bloodvessel. Some 
physicians have recommended ipecac in full nauseating doses to 
relax the arterial system. Sometimes, when the oozing is slow, tur- 
pentine, oil of erigeron, or hamamelis, taken internally, does good. 
In the way of local treatment by far the best application, because it 



ERYSIPELAS 779 

is efficacious and yet harmless, is adrenalin chloride in salt solution 
1 : 1000, which should be placed in the nasal chambers on a piece of 
cotton, or compound tincture of benzoin may be used in a similar 
manner pressed against the septum. If this does not control the 
hemorrhage, an atomized spray of Monsel's solution, in the strength 
of 5 minims to the ounce (0.3-30.0) of water, may be of service. (See 
Coagulose.) 

The non-medicinal measures to be employed if the bleeding is 
severe consist in plugging the anterior nares with pledgets of cotton 
or pieces of lint soaked in adrenalin solution or weak vinegar. If 
this does not control the hemorrhage, the posterior nares may also 
be clpsed by plugs, and compression of the facial artery of the same 
side as the bleeding nostril be made upon the superior maxilla near 
the nose, thus decreasing the blood supply. The head must be 
kept raised, and the patient must not bend over a basin or wear a 
tight collar. 

A piece of bacon fat cut to fit and placed in the nostril may stop 
epistaxis which has resisted other measures. 

As a household remedy diluted vinegar may be injected into the 
nostrils, or lemon-juice may be employed in the same way. 

Sometimes, if the patient raises one or both hands high above the 
head, the hemorrhage ceases. This is due to the fact that the easiest 
pathway for most of the blood is straight up the brachial arteries 
rather than through the tortuous vessels of the face. A hot foot- 
bath, by dilating the veins of the lower extremities, draws away 
the blood from the face and is a useful measure; but if bleeding 
has been profuse, this may cause the patient to faint unless he lies 
down when his feet are in the water. In other cases a hot- water 
bag applied over the dorsal vertebra? is efficacious, and sometimes 
cold when so used is of service. A piece of ice pressed against the 
nose may prevent further hemorrhage by causing localized anemia. 

Where the nasal hemorrhage results from traumatism with fract- 
ure of the bones, and the great loss of blood ensues, compression 
of the bleeding vessel or its supplying vessel should be made if 
possible. 

ERYSIPELAS. 

This disease is now generally recognized as dependent for its exist- 
ence upon the streptococcus of erysipelas, and the disease is at first 
a distinctly local one. The changes which have taken place in its 
treatment are chiefly the local measures, while those methods which 
have been used internally for many years have undergone no 
alteration. 

In a large proportion of cases erysipelas develops because the 
vital resistance of the patient Jias been lowered by some acute illness 
or by a chronic malady like nephritis or diabetes. For this reason 
its spread in the skin and the toxemia it causes must be controlled 



780 DISEASES 

by the employment of every measure that will enable the patient to 
combat the infection. Rest in bed is essential and supporting treat- 
ment is demanded. 

The internal treatment of erysipelas par excellence is the plentiful 
use of the tincture of the chloride of iron— 20 to 30 minims (1.3- 
2.0), or even 40 minims (2.6), well diluted, four times a day. The 
diet should be regulated and the bowels kept in good order. Any 
excessive febrile movement is to be treated by the use of cool spong- 
ing with friction. If the patient passes into a typhoid state sup- 
portive measures must be used and alcoholic stimulants added to 
the food, which should be predigested or prepared so as to be readily 
absorbed. 

During convalescence the use of tonics, both in the form of iron 
and of bitters, is particularly indicated if recovery of strength is 
slow. 

The local treatment of erysipelas is very various, but in the major- 
ity of cases resort need be had to but one method. By far the best 
dressing for the majority of cases of erysipelas is a modification of 
that of von Nussbaum, which the author has tried in a great number 
of instances with success. The skin of the part involved is care- 
fully cleansed with Castile soap of the purest form, and then it is 
washed off with a 1 : 1000 solution of bichloride of mercury. The 
skin is dried with a soft towel, and a thick coating of ichthyol with 
lanolin applied, the strength of this ointment being half and half. 
Over this is placed antiseptic gauze or sterilized absorbent cotton, 
and adhesive strips or a bandage is used to keep the dressing in 
place. Sometimes the ointment alone may be applied if the area 
is small. Under this treatment the results are often extraordinary 
in all stages of the malady. Where ichthyol is not obtainable, a 
thick coat of white-lead paint, as it is sold in cans before it is mixed 
with any thinning substance, will be found of service in an emergency. 

The iron and ichthyol method is that always followed by the 
author. (See also Magnesium Sulphate.) 

The plan recommended by Higginbottom, of applying nitrate of 
silver, is sometimes successful. It consists in the use of a solution 
of the strength of 80 grains to 4 drams (5.3-16.0) of distilled water, 
which is thoroughly applied with a camel's-hair brush over the 
entire inflamed area and for a little space beyond. The application 
must be made twice or thrice to secure a good coating. This treat- 
ment will often arrest the inflammation and prevent its spread, 
but has caused sloughing; the author has never used it. 

EXHAUSTION AND DEPRESSION. 

While the treatment of both these conditions is almost identical in 
some respects, it is nevertheless important that a clear idea of the 
difference between the two be clearly understood, if for no other 



EYE-STRAIN 781 

reason than that the physician may recognize that exhaustion is a 
far more serious state than depression. It also requires more careful 
treatment. The man who is depressed retains in his body all the 
vital forces necessary for the maintenance of life, but they are tem- 
porarily in abeyance from some cause. As soon as the incubus is 
taken away the system at once asserts itself and recovery takes 
place. This is not the case with a man suffering from exhaustion. 
In this patient his strength is sapped and lost. The man depressed 
is the giant lying unconscious from a blow on the head; the man 
exhausted is the same giant after a long attack of typhoid or other 
fever of a similar nature. The treatment of depression is stimula- 
tion; of exhaustion, not only stimulation, but rest, feeding, and 
protection from exposure. 

EXOPHTHALMIC GOITER. 

It is not possible to lay down a definite plan of treatment for 
this disease because patients present symptoms varying so greatly 
in gravity that measures directed toward one case may be futile or 
harmful in another. The measure which is first in importance in 
all cases is rest in bed in a quiet room with relief from all cares and 
responsibilities. In certain cases after some days a regular rest 
cure may be undertaken. The use of nervous sedatives such as the 
bromides or barbital to produce sleep may be resorted to as symp- 
tomatic remedies. The diet should consist largely of milk, fats 
and starches with very moderate amounts of meat, as much protein 
food is thought to stimulate the thyroid gland. Such a rest should 
be continued for several weeks and followed by partial rest for some 
weeks. Rest may therefore be considered as a method of cure, and 
in well-developed cases as a great help in those cases which are to be 
treated chiefly by the .r-rays or radium, which agents are nearly 
always to be tried before resort to surgery as one or both give excel- 
lent results in many cases. A great many surgical measures have 
been tried— from injecting steam or destructive agents into the 
gland to tying the arteries supplying the gland or partial thyroidec- 
tomy. Even when surgical measures are to be followed it is almost 
as essential that a period of rest in bed shall precede interference. 

EYE -STRAIN. 

Eye-strain, in the broadest acceptation of the term, is the name 
applied to those symptoms which may be caused by the presence of 
refractive error, or imbalance of the ocular muscles. While all 
varieties of ametropia may cause eye-strain, hypermetropia and 
astigmatism are most potent in this respect. Fully 75 per cent, of 
functional headaches are caused by refractive errors; and these 
headaches may vary from a moderate frontal distress to violent 



782 DISEASES 

explosions of pain, and may be situated in any portion of the cra- 
nium. Moreover, they may be entirely unassociated with any 
pain in the eyes or any apparent disturbance of vision, and are 
frequently caused by low degrees of refractive error; in fact, they 
are perhaps more frequently caused by them than by the higher 
defects. In addition to headache, eye-strain may cause pain in 
the back, especially between the shoulder-blades and at the root 
of the neck, precordial pain, vertigo, drowsiness, insomnia, habit- 
chorea, choreiform movements, convulsive seizures, melancholia, 
neurasthenia, palpitation of the heart, syncope, night-terrors, stom- 
achic disturbances, constipation, flatulent dyspepsia, and a variety 
of general or so-called reflex neuroses. The existence of any of 
these symptoms or affections should direct the attention of the 
attending physician to the condition of the eyes, and refractive error 
and muscular imbalance should be corrected. Certain cases of 
so-called spinal curvature, head tilting, head nodding, and torticollis, 
in young persons are due to the influence of ametropia and impaired 
muscle balance. 

FEET SWOLLEN, TENDER, OR SWEATING. 

These comparatively simple yet annoying conditions are often 
brought before the physician for relief, and patients suffering from 
them will frequently be more grateful for skilful treatment than in 
the event of recovery from a severe illness. 

Swelling of the feet occurs chiefly in two classes of cases, except- 
ing, of course, dropsy. The two classes named are old persons 
taking too little or too much exercise, and who may have gouty 
or rheumatic tendencies, and those who by constant standing or 
walking cause congestion of the lower extremities, chiefly by fatigue, 
or by wearing ill-fitting shoes, or by running over uneven ground, 
causing bruising. Where the swelling takes place in the first class, 
small doses of arsenic trioxide, eV to to grain (0.001-0.0015), often 
do good, and careful examination should be made of the circulatory, 
renal and respiratory apparatus to discover any weak points, such 
as vascular relaxation or tendencies to varicosities. The distilled 
or fluidextract of hamamelis is often of service in the dose of \ to 
1 dram (2.0-4.0) of the former and 10 to 20 minims (0.6-1.3) of the 
latter preparation. In some cases absolute rest of the feet will be 
necessary before a cure is reached. 

Where the feet are tender a common cause is bruising from too 
thin soles on the shoes, too tight shoes, and from abrasions or skin 
disease. More commonly than all they become sore from excessive 
sweating and resulting maceration. In some instances the pain is 
due to a broken-down instep. The pain is often treated as rheu- 
matism. 

The treatment of sweating and tender feet is, of course, the removal 



FEVER AND ITS TREATMENT 783 

of the cause and the use of remedies designed to toughen and harden 
the skin of the parts. Probably the best application for this purpose 
is a solution of salicylic acid and borax, half and half, in water and 
glycerin, rubbed over the feet night and morning. If the sweating is 
very profuse, clean stockings should be worn each day, the stockings 
being previously soaked in a strong solution of borax and dried. 
The following prescription affords a useful powder: 

]$— Pulveris acidi salicylici gr. xx vel xl (1.3-26) 

Pulveris acidi borici 5ij (8.0) 

Pulveris amyli q. s. ad gj (30.0).— M. 

S. — To be dusted over the feet night and morning, after washing and thoroughly 
drjdng them. 

One of the most efficient applications is a solution of formaldehyde 
of such strength that 1 part of the commercial 37 per cent, solution 
is mixed with 4 parts of water. Even this may be too strong in 
some cases. A more agreeable application is diluted Euformol. 

Sometimes the use of cotton instead of woollen stockings may 
aid in the cure. 

FEVER AND ITS TREATMENT. 

(For the Treatment of each Fever, see its Title.) 

At the present time the medical profession is universally of the 
opinion that fever is a disorder of calorification dependent upon 
nervous action, said nervous action being the result of various 
causes, such as the presence of poisonous materials in the blood 
causing perverted functional activity of the heat center. The rule 
of practice should be to control all fevers that need control by the 
use of cold sponging or bathing and to resort to antipyretic drugs 
as little as possible. 

Antipyretics may be divided into three great classes: first, the 
substances which allay or prevent fever by inhibiting its produc- 
tion; second, the drugs which possess the power of decreasing bodily 
temperature by increasing the dissipation and decreasing the pro- 
duction of heat; and third, the compounds which allay fever, not by 
stopping the development of heat-units, but by so increasing the 
dissipation of heat that the loss is greater than the production. The 
first and last of these classes are directly opposed to one another. 
The second class is half-way between, and it is to this class that most 
of our antipyretic drugs belong. 

The objection to the use of all antipyretic drugs is that they 
depress the patient and decrease his power of resisting disease. 

The presence of a high temperature alone does not constitute the 
sole indication for treatment. The physician should be governed by 
the state of the patient who is laboring under the malady. A tem- 
perature of 106° F. in a young healthy man suffering from an attack 
of some disease of short duration does not mean very great danger, 



784 DISEASES 

but a temperature of 103° F. day in and day out in typhoid fever 
does mean danger, chiefly because it is a gauge of the toxemia, and 
must be carefully attended to. The question is one not of actual 
degrees of Fahrenheit, but rather as to whether the state of the 
patient is toxic. 

We have only two measures for the relief of fever which are reliable. 
These are the employment of antipyretic drugs and the use of cold 
water. As already ated, drugs are to be used very rarely, but the 
beneficent effects of the use of cold water are extraordinary, and it 
should be freely employed if the fever is too high. (For the mode 
of using acetanilid and antipyrine see Part II, and for the use of 
cold see Part III.) 

The friends of the patient, if they are intelligent, can easily be 
taught how to use cold sponging with friction, and good results, far 
superior to those produced by antipyretic drugs, are thus obtained. 
The reasons for this are discussed farther on. The water should be 
as cold as is necessary to reduce the fever satisfactorily in twenty 
minutes of sponging, and reaction must be produced by friction 
applied to the skin. This reaction is more important than the 
reduction of the fever. (See Cold in Fevers, Part III.) 

Asthenic Fevers. 

(Fevers of a Typhoid Type.) 

In the opinion of the author antipyretics should not be employed 
in the reduction of the pyrexia of the typhoid state, our main reliance 
being upon cold applications. They ought never to be combined 
with the cold bath, as they prevent the one thing we seek in the 
use of the cold, namely, reaction. Aside from the fact that the 
author has found such an opinion well founded in a large number 
of cases, logical reasoning endorses its correctness. Even if anti- 
pyretics were perfectly innocuous, their constant use in fever would 
but give the already overstrained kidneys the task of their excretion, 
while the stomach, already disturbed by necessary medicines and 
illness, has enough to do without the addition of another load. 
Further than this, we know that these drugs are not perfectly harm- 
less, and we also know that they decrease oxidation, which is not the 
case with the cold bath, which increases it. The writer reiterates 
that in typhoid and other low fevers of the continued type antipy- 
retics should not be given. (For Brand's treatment, see Cold, Part 
III, and Typhoid Fever, Part IV.) Fever will sometimes resist all 
doses of antipyretics we can give or all that is it safe to give, but 
no fever can completely resist the cold sponge when properly used, 
for by its use we produce beneficial results by reaction even if an 
actual fall of temperature does not take place. In septic fever and 
in tuberculosis antipyretics are harmful owing to the depression and 
the increased sweating which is apt to be produced. 



FRECKLES AND CHLOASMA 785 

Sthenic Fevers. 

The application of antipyretic drugs to the febrile temperatures 
occurring in sthenic cases is not so irrational as their employment in 
a prolonged low fever of the adynamic type, but the wise physician 
will always endeavor to avoid their use if possible. Fever is not, 
as a rule, a very harmful process unless it is continued for a long 
period or is exceptionally high. Indeed it may even be beneficial. 
Antipyretic drugs decrease oxidation, probably interfere with ordi- 
nary protective natural efforts against disease, and place upon the 
eliminating organs the task of excretion. In acute illnesses, if the 
use of cold is impossible, these remedies may be given, but usually 
it is unnecessary to employ them, for unless the fever is long con- 
tinued it is not harmful in itself. In scarlet fever the use of such 
drugs should be avoided, because the kidneys are in danger. 

If in any case it is decided to give antipyretic drugs, they should 
never be pushed to the point at which even moderate cyanosis 
develops; and if they do not control the fever in moderate dose, 
they should be discarded and cold bathing insisted upon. The use 
of antipyretic drugs and cold sponging simultaneously is absolutely 
harmful. 

Personally the writer never under any circumstances employs 
antipyretic drugs for the reduction of fever. 

In thermic fever, or sunstroke, the employment of antipyretics is 
often useless. The excessively rapid upward rise of the temperature 
responds in no way to drugs, and there are many cases on record 
in which the use of antipyrine has utterly failed of good result. 

FRECKLES AND CHLOASMA. 

The removal of freckles is readily accomplished, but their return 
is inevitable if any exposure to the sun or wind occurs. One of 
the best applications for their removal is a solution of corrosive 
sublimate, in water, varying in strength from 1 to 4 grains to the 
ounce (0.06-0.25:30.0), and applied night and morning until the 
skin shows that it is irritated, when the lotion must be stopped for 
some days, after which its use may be begun again. A very efficient 
and much less poisonous remedy to leave about the room is a satur- 
ated solution of boric acid in water, applied in the same manner as 
is the solution of bichloride of mercury. 

Another remedy is lactic acid, 10 grains to a dram (0.6:4.0) of 
water, used in the same manner as the solution of the bichloride 
of mercury. The following prescription is recommended by Unna: 

]$ — Bismuthi oxidi, 

Pulveris amyli aa gr. xxx (2.0) 

Kaolini 3j (4.0) 

Glycerini f3ij (8.0) 

Aquae rosae q. s. ad fgij (60.0). — M. 

S. — Paint on spots and allow to dry, washing the drug off before each new application, 

50 



786 DISEASES 



Or the following may be used: 

]$ — Zinci oxidi .... 
Hydrargyri ammoniati 
Olei theobromatis 

Olei ricini 

Essentise rosse 

S. — Apply night and morning. 



gr. iij (0.2) 

gr. iss (0.08) 
f3iiss (10.0) 
f3iiss (10.0) 

gtt. x (0.6).— M. 



GASTRIC CATARRH (ACUTE). 

By far the most important point in the treatment of acute gastric 
catarrh is the regulation of the diet. The dietetics may be divided 
into two parts— first, the regulation of the food during convalescence 
or during the attack; and, secondly, the character of the food to be 
used during the interval following one attack and preceding the next. 
Total abstinence from food in the acute stages of the attack, and 
absolute bodily and mental quietude, are advisable. There are 
several reasons for this. In the first place, the juices of the stomach 
are in an abnormal state and unfit to act properly if the stomach 
receives more food. Secondly, the mucous membrane of the stomach 
is already hyperemic from the inflammation, and, as the normal 
viscus becomes physiologically hyperemic on the ingestion of food, 
we would add to the congestion of the bloodvessels did we allow more 
nourishment to enter the stomach. Last of all, the excess of the 
mucus and lactic and butyric acids present renders any new food 
impure before it can be assimilated, and so prolongs the trouble. 
As the attack passes off small amounts of food may be given, which 
should be of a kind readily digested and not likely to become easily 
decomposed or rendered acrid. Milk with a large percentage of 
lime-water or citrate of sodium is to be used to prevent a too firm 
coagulation and to decrease the secretion and acid reaction of the 
mucus. The thirst is often excessive, although anorexia is complete, 
and small pieces of ice may be administered for its relief. Small 
doses of bismuth subnitrate (grains 2 [0.12]) and of cerium oxalate 
(grain 1 [0.06]) every two hours are advisable for children. 

Commonly it will be found that the patient rapidly improves up 
to a certain point, then stops improving or relapses. This is some- 
times due to an accumulation of mucus, which when mixed with 
food causes it to undergo fermentation. If marked evidences of 
the presence of this secretion are given, a mild and gently acting 
purge, such as milk of magnesia, followed by a little orange-juice, 
may be employed to dislodge the fermenting mass. In other instances 
the relapses depend upon a tendency to a condition of atony, which 
can only be overcome by prolonged and careful treatment adapted 
to the improvement of the general health. Sodium bicarbonate 
with compound infusion, or compound tincture, of gentian may be 
used during convalescence, and small sips of effervescing draughts 
are useful. If constipation exists and vomiting forbids the use of 



GASTRIC CATARRH 787 

the ordinary purgatives, a Seidlitz powder divided into fourths or 
fifths, and taken in this way every fifteen minutes or half-hour, will 
settle the stomach, move the bowels, and often carry away mucus. 

If there is much epigastric distress, a spice or mustard poultice 
is often of service. 

Sweets and starches are to be rigidly denied the patient. If 
anemia exists, iron may be used, but this is rarely needed. 

The abdomen should be carefully protected with flannel, and 
draughts and unsanitary surroundings avoided. 

GASTRIC CATARRH (CHRONIC). 

Chronic gastric catarrh is a condition of the stomach commonly 
seen in a more or less well-developed form. It is often associated 
with much indigestion and the eructation of sour liquids, or even 
with active vomiting. The secretions of the stomach are nearly 
always abnormal, and fermentative changes are constantly present 
in the gastric contents. Lavage is almost always to be resorted to 
for its relief. (See Lavage, Part III.) 

By far the best treatment for this condition is the use of counter- 
irritation over the epigastrium by means of tincture of iodine, the 
strict regulation of the diet, and the use, internally, of nitrate of 
silver and extract of hyoscyamus, and, if great hyperacidity exists, 
the administration of the subnitrate of bismuth. Often, however, 
the better remedy is bicarbonate of sodium in the dose of 5 to 20 
grains (0.3-1.3). In many instances the patient will be greatly 
benefited by the use of a Seidlitz powder or Carlsbad salt 1 or Abilena 
water before breakfast each morning, as this washes out the stomach, 
dissolves the mucus, and unloads the mucous membrane of its con- 
gestion, at the same time overcoming any engorgement of the liver. 
The efficiency of these purgatives may be increased by following 
them with a draught of hot water. Constipation is nearly always 
present, and should be relieved by appropriate drugs such as the 
waters just named or cascara sagrada, of which the best prepara- 
tion is the aromatic fluidextract, rendered free from bitter taste, as 
in ' 'cascara evacuant." 

All fats, rich foods, strong meats, ham, bacon, and fried foods 
are to be avoided, and only light broths, koumyss, or matzoon 
resorted to if the case be an obstinate or severe one. A nitrate-of- 
silver pill should be used half an hour before each meal, and be 
prescribed as follows: 

]$ — Argenti nitratis gr. iv (0.25) 

Extracti hyoscyami gr. x (0.6). — M. 

Fiant pilulse, No. xx. 

S. — One pill half to one hour before each meal. 

1 Artificial Carlsbad salt may be ordered, composed of 8 ounces of sodium phosphate, 
| ounce of sodium chloride, and 1 ounce of sodium carbonate. The dose varies from 
2 drams to \ ounce (8.0-16.0). 



788 DISEASES 

In cases in which the chronic inflammatory process has gone on 
to atrophy of the tubules the use of hydrochloric acid is often of 
great value. (For formula, see Hydrochloric Acid.) 

GASTRIC DILATATION. 

Gastric dilatation is to be treated with two objects in view, namely, 
the relief of the symptoms and the correction of the gastric condi- 
tion as far as possible. The relief of the symptoms depends upon 
the suitable regulation of the diet, the proper use of washing out 
the stomach (lavage), and the use of other remedial measures. All 
these efforts also tend to relieve or modify the underlying gastric 
state in that they remove certain influences which, if continued, 
would necessarily make the condition of the patient worse. The 
actual state of dilatation when once developed cannot be materially 
improved. In the way of diet, all articles bulky in character, such 
as cabbage, and those foods which are slow of digestion and capable 
of rapid fermentation should be excluded. Particularly is this true 
of rich or fatty foods, and of drinks such as beer and ale. When 
food is given, it is to be administered in small amounts and often, 
rather than in large, full meals, and it should consist chiefly of 
roasted and broiled meats, easily digested starches, such as "Zwei- 
bach" bread or "pulled bread," and the green vegetables, like lettuce, 
asparagus, string beans, and moderate amounts of spinach. To 
aid in the digestion of vegetable foods 5 to 10 grains (0.30-0.65) 
of taka-diastase should be taken with each meal, and to this may 
be added a little powdered capsicum to stimulate the stomach. 
Where gastric digestion is very faulty, predigested food and rectal 
alimentation should be employed for a time. In the way of direct 
treatment, the stomach of the patient should be washed out with 
the stomach-tube at least once a day; and if fermentation is active 
and food is apt to be retained in this organ, it should be thoroughly 
cleansed before each meal, and some mild antiseptic, like boric 
acid, used in the washing fluid. Lavage not only removes decom- 
posing food and mucus, but also exercises a beneficial effect on 
the gastric walls. The water used should not be cold nor tepid, but 
hot, and may contain 1 dram (4.0) of boric acid to the pint (480 
cc). Faradic electricity applied to the epigastrium or to the 
stomach direct by a swallowed electrode is useful. In the way of 
direct treatment by drugs, the physician should use full doses of 
dilute hydrochloric acid to aid digestion, say, 20 to 30 minims (1.3- 
2.0), and give strychnine in full doses to aid this function, and also 
to increase the motor power of the stomach, so that it will urge the 
food on into the bowel. Often the lavage, electricity, and strych- 
nine combined will produce great improvement. General hydro- 
therapy in the form of cold douches to the entire body, and exercise 
on horseback or on foot, are valuable in many cases. If fermentation 



GASTRIC AND DUODENAL ULCER 789 

is marked, antiseptic substances, like betanaphtol, may be employed 
internally. As the majority of cases are due to some obstructive 
lesion at the pylorus this possibility should be investigated and, if 
present, surgical relief sought. In many instances gastroptosis is 
marked; a supporting belt should be worn. 

GASTRIC AND DUODENAL ULCER. 

In the treatment of gastric ulcer three points must be borne in 
mind as being essential. These are, rest for the stomach as far as 
possible, rest for the patient, and the maintenance of the general 
health. The first of these, points involves a consideration of diet. 
It is best to place the patient in bed and nourish her for from two 
to eight days by means of enemata, or, much better, if the physician 
is skilled in its use, by the duodenal tube. Probably the best form 
of nourishment by enema is a glucose solution given by the Murphy 
drip, whereby the body is supplied with plenty of fluid. (See Part 
III, and Peritonitis, Part IV.) After this treatment has been used for 
some days, small quantities of food may be given by the mouth, such 
as a little peptonized milk or a little warm milk with lime-water in 
the proportion of half and half, or one part of lime-water to two of 
milk. After this, thin arrow-root or gruel may be given in moderate 
quantity, with taka-diastase to aid its digestion. It is better to give 
the food in small amounts every two hours than in larger quantity 
three times a day. 

The increase in rations, both as to variety and amount, should 
be most gradual, the physician extending the dieting over at least 
six weeks, of which the first two had best be spent in bed. It is 
well to use massage and electricity under these circumstances to 
preserve nutrition, as in the rest cure. (See Rest Cure.) Beef-tea 
and soups had better be avoided during the early stages of the treat- 
ment, as they will irritate the stomach. Soft-boiled eggs, tender 
chicken or game, and minced lamb may be finally given. Cheese, 
coffee, tea, beer, and ale are to be avoided, as are all very hot drinks. 
Fresh green vegetables may be used in moderation, but fresh bread 
and unripe fruit must be carefully avoided. When milk is taken 
it should be warmed. The presence of gastric pain indicates that 
the diet must be cut down in quantity and the nutrition maintained 
solely by rectal injection. 

On the principle that healing of the ulcer will not take place in 
the presence of a condition of general malnutrition and acidity, 
Lenhartz has opposed the starvation method of treating gastric 
ulcer, and has advocated the use of small quantities of food to be 
given every hour, so that the nutrition may be improved without 
the stomach at any time being overburdened or distended. The 
stomach is given absolute rest between 7 f.m. and 7 a.m. Lenhartz's 
treatment consists in absolute rest in bed for a month and in feeding 



790 DISEASES 

the patient with small quantities of beaten-up eggs and milk, the 
quantities being increased day by day. An ice-bag is kept constantly 
applied to the epigastrium, and after the first week soft-boiled rice, 
minced meats, and semisolid and solid foods are gradually allowed. 

Another advantage which is claimed for this method is that the 
food takes up the free hydrochloric acid and so prevents it from 
acting upon the ulcer, and the well-known fact that taking of food 
often relieves the pain of gastric ulcer is advanced as an argument 
in support of this view. The actual quantities of foods allowed by 
Lenhartz consist on the first day of from 7 to 10 ounces of milk 
with one egg, and the increase is 3J ounces of milk each day and 
one egg each day until a quart of milk and six to eight eggs are 
ingested. The amount of meat first given is 2 ounces. The bowels 
are not disturbed by treatment during the first week, but they 
are not prevented from moving naturally. If they do not move 
naturally an enema is given every fourth day during the rest of the 
treatment. Although the number of calories which the patient 
receives during the first few days is considerably below the number 
actually required for the maintenance of nutrition, the gradually 
increased quantities of food soon bring the calories up to about 
3000 per day, which is fully as large as an individual in perfect health 
needs to ingest. He claims that the number of instances of hemor- 
rhage are materially decreased by this method, as is also the per- 
centage of relapses. This form of treatment, while advantageous 
in some cases, is not applicable in those instances in which the 
taking of food produces great pain, but it is the plan I commonly 
employ. 

The drug treatment of these cases is palliative as to pain, and 
curative. For the pain, counterirritation of a more or less severe 
and constant type should be applied to the epigastrium, either as 
a spice or mustard plaster or by means of a hot-water bag. The 
counterirritation should be as continuous as possible. Sodium 
bicarbonate and the subnitrate or subcarbonate of bismuth are 
also of service in the dose of 20 grains (1.3) each, and to these may 
be added from to to \ grain (0.003-0.015) of morphine sulphate, 
i to § grain (0.015-0.03) of dionin, or 1 grain (0.06) of codeine. 
These may be given thrice daily if necessary. Only the smallest 
dose of morphine necessary to relieve the pain should be employed. 
A valuable treatment for the pain and for the acidity is the following 
pill: 

1$ — Argenti nitratis gr. iv (0.25) 

Extracti hyoscyami gr. x vel xx (0.6-1.3). — M. 

Fiant pilulae, No. xx. 

S. — One pill half to one hour before meals. 

Another useful drug in such cases is chloretone in 5-grain (0.3) 
doses, given in capsule three times a day half an hour before food. 
When great gastric acidity is present, which is not controlled by the 



GASTRIC AND DUODENAL ULCER 701 

pill named above or by the use of chloretone, the following formula 
may be employed: 

1$ — Sodii bicarbonatis, 

Magnesii oxidi ponderosi, 

Calcii carbonatis aa 5 j (30.0) 

Olei menthffi piperita? TUx (0.6). — M. 

S. — A saltspoonful every two hours in a little water. 

For the constipation which is frequently present the patient may 
receive a dose of Carlsbad salt or phosphate of sodium, or even the 
sulphate of magnesium before breakfast, although it is best, as a 
rule, to rely upon an enema each day to produce a movement. 

For the relief of vomiting and of hematemesis absolute abstinence 
from food, so far as its administration by the mouth is concerned, 
is to be insisted upon for a period of several days. Nutrition must 
be maintained under such circumstances by feeding by the rectum 
with glucose. (See Part III.) If the vomiting is persistent, small 
doses of cocaine, i grain (0.015), may be given, or cocaine and bis- 
muth subnitrate combined. Sometimes 2- to 3-grain doses of ace- 
tanilid are useful, or phenol may be given in the same dose with 20 
grains (1.3) of subnitrate of bismuth. If there is hematemesis good 
results may follow the use of a dram of the solution of adrenalin 
chloride, or of the solution of the sub sulphate of iron (Monsel's solu- 
tion) in the dose of 3 minims (0.2) in a little water every half-hour. 
Cold compresses or an ice-bag may also be applied to the epigastrium 
for the same purpose unless the hemorrhage is so profuse as to lower 
the patient's temperature. 

Should perforation of the stomach occur, operative interference 
is to be promptly resorted to after the shock has been treated by 
supportive treatment in the way of heat to the limbs and the hypo- 
dermic use of ether, brandy, and atropine. Morphine should also be 
given freely unless collapse is too pronounced, as it tends to diminish 
abdominal pain and inflammation. 

In obstinate cases of ulcer with much pain and evidence of a 
severe lesion a surgeon of experience should perform gastroenter- 
ostomy or gastrojejunostomy, to permit healing of the ulcer, with 
or without excision, particularly if there has been repeated hemor- 
rhage. The decision as to whether a physician or a surgeon should 
take charge of a case of gastric ulcer may be determined on the 
following facts: 

When the symptoms are the ordinary ones of gastric distress or 
indigestion the case is medical. If there are signs of pyloric obstruc- 
tion, as represented by retention, vomiting or dilatation, or hour- 
glass contraction, adhesions which interfere with function, or repeated 
hemorrhage, the case is surgical, the more so if there is a long history 
of gastric trouble. The possibility of a chronic ulcer ultimately 
becoming malignant is also to be borne in mind when an operation 
is considered. 



792 DISEASES 

Two final points are to be borne in mind, viz.: Every case of 
gastric ulcer should be told that medical cure is not a matter of 
days or even weeks but months or years. Weeks for the relief of 
distress and ability to take food and years, if cure, in the sense that 
dietary restrictions can be ignored. The second point is that opera- 
tion is not always curative entirely apart from its immediate danger. 
If prolonged dietetic and medical treatment are really impossible 
operation may be justified. 

Duodenal ulcer is to be treated medically or surgically, the latter 
method being used when the condition has lasted so long that healing 
is not likely to occur, when the pain is severe or the general health 
and comfort of the patient cannot be maintained by medical means. 
The occurrence of an intestinal hemorrhage severe enough to jeop- 
ardize life indicates operation to prevent recurrence, but not until 
the patient has rallied, and, in most instances, not until the cor- 
puscular and hemoglobin content of the blood are high enough to 
make surgery safe. Surgery is indicated when the constant presence 
of occult blood in the stools, or repeated small hemorrhages, shows 
that the ulcer is leaking this fluid and if the hemoglobin is not below 
50 per cent. 

The medical treatment is as follows: The associated gastric 
hyperacidity with pyloric spasm may be controlled by \ dram (2.0) 
of sodium bicarbonate dissolved in water half-way between meals. 
Milk of magnesia in ^-ounce doses may be taken at bedtime or 
during the night to relieve distress. Mineral oil may be used to 
soothe and protect the ulcer and for overcoming intestinal stasis. 
If the acidity is very severe full doses of extract of hyoscyamus, 
as \ grain (0.02), as it is more sedative than belladonna, may be 
given in pill. In some cases excellent results follow resort to duo- 
denal feeding by the duodenal tube. For associated anemia iron 
citrate and sodium of cacodylate may be given hypodermically 
(which see). The diet should be that employed in the treatment 
of gastric ulcer. 

GASTRITIS (ACUTE). 

This is generally due to the ingestion of irritant poisons or foods, 
rarely arising in its true acute form from other causes. 

The treatment is to be directed entirely to the prevention of the 
spread of the inflammation and to the relief of that already devel- 
oped. If the patient is seen soon after the onset of the trouble, 
the stomach is to be emptied of all irritant substances by means of 
vomiting induced by large draughts of warm water, or, better still, 
by the use of the stomach-tube, as the retching may increase the 
irritation. Mucilaginous drinks are to be given freely, and albu- 
minous materials seem especially useful. Oils and similar protective 
liquids aid in preventing further damage. Opium, to ally pain and 
the local and systemic irritation, is invaluable. This drug should 



GLA UCOMA 793 

always be given in liquid form, and the deodorized tincture is the 
best in this respect, owing to its freedom from narcotine. Paregoric 
contains too little opium to be of value. If the stomach will not 
retain drugs, they should be given by the rectum. 

GASTROENTERITIS. 

Gastroenteritis is a condition of inflammation affecting the entire 
alimentary canal in some instances, and commonly produced by the 
ingestion of some irritant substance, either in the form of bad food, 
poisons, or mechanical irritants, such as grape-seeds or cherry-stones. 
The symptoms accompanying it are exceedingly various, but con- 
sist chiefly in pain of a griping character, with watery or mucous 
stools, or, if the inflammation be very severe, absolute and unyield- 
ing constipation may be present. The nervous symptoms depend 
upon the degree of irritation and the general nervous tendency of 
of the patient; and if the trouble is very severe, a condition of 
collapse may result. 

If the irritation is very intense, exfoliation of the mucous mem- 
brane may take place, the epithelium coming away in shreds. 

The treatment of gastroenteritis depends upon its severity and 
cause. Almost always we first allay the pain and tendency to inflam- 
mation by the hypodermic use of morphine, and immediately follow 
this or precede it by an emetic of a non-irritating and rapidly acting 
type, such as apomorphine, provided there is reason to believe that 
the poison or food still remains in whole or in part in the stomach. 
If the irritant has been taken some time before the physician is 
called to see the case, emetics are contraindicated, as by disturbing 
the abdominal contents they increase the inflammation. If the 
irritant has passed the pylorus, castor oil, in the dose of 2 to 3 table- 
spoonfuls (30.0-45.0) to an adult, may be given to sweep out the 
offending materials and lubricate the intestinal walls. The sulphate 
of magnesium is of value, because, in addition to its purgative effect, 
it also depletes the inflamed bowel. Having got rid of all offending 
materials, opium is to be freely used to ally irritation and control 
diarrhea (see Diarrhea), and hot compresses are to be applied to 
belly, or a spice or mustard plaster used instead. (See article on 
Diarrhea.) Vomiting when excessive is to be treated in the manner 
described under that head. The after-treatment of acute gastro- 
enteritis is very important, both in respect to food and drugs. Pre- 
digested foods are, therefore, in many cases indispensable, and a 
carefully regulated diet is a sine qua non. The abdomen should be 
protected from cold by a flannel binder. 

GLAUCOMA. 

Glaucoma, a disease dependent upon an increase of intra-ocular 
pressure, appears in an acute or a chronic form. The affection in 



794 DISEASES 

general terms is characterized by halos appearing about artificial 
lights; periods of obstruction of sight; shrinking of the nasal half 
of the field of vision, narrowing of the anterior chamber of the eye; 
anesthesia of the cornea; and increased tension of the eyeball. In 
the "glaucomatous attack," or acute glaucoma, the injection of the 
eyeball is intense; the lids swell, there is photophobia, the cornea 
is steamy, the pupil dilated and motionless, the tension of the eye- 
ball is greatly raised and the globe cannot be dented by the pal- 
pating fingers, and the vision rapidly destroyed. The condition 
may be mistaken for iritis or acute conjunctivitis— a fatal blunder. 

Acute glaucoma should be treated locally with myotics. Of these 
the best are eserine, in the form of the sulphate or the salicylate, 
in a strength of 1 to 4 grains to the ounce, or hydrochloride of 
pilocarpine in a strength of 2 to 5 grains to the ounce. One drop of 
such a solution should be instilled with sufficient frequency to con- 
tract the dilated pupil and to keep it in a state of contraction. The 
action of the myotic may be enhanced by the application of hot 
compresses and corneal analgesia established by the use of dionin 
in 5 per cent, solution. Atropine and all mydriatics are strictly 
contraindicated. Internally full doses of salicylate of sodium should 
be administered. If the pain is very severe there is no objection 
to a hypodermic injection of morphine. The surgical treatment of 
acute glaucoma is usually necessary, preferably a broad iridectomy, 
and this operation should be performed unless the myotics are 
speedily efficacious. 

In so-called chronic glaucoma, in which there are no inflammatory 
or congestive symptoms, but in which there is a progressive atrophy 
of the optic nerve with cupping, associated with diminution of the 
light-sense and contraction especially of the nasal field of vision, 
and in which the diagnosis is made by means of the ophthalmoscope 
myotics are useful and should be employed in a strength not so great 
as that recommended for acute glaucoma, but with sufficient fre- 
quency to maintain a contracted pupil. The intra-ocular tension 
should be frequently tested with a tonometer. Should myotic 
action fail, or should the disease progress in spite of them, iridectomy 
or one of its substitutes may be employed, but the best surgical 
procedure is an operation which creates a filtering cicatrix; for 
example, Lagrange's combined iridectomy and sclerectomy, or Elliot's 
corneoscleral trephining or iridotasis. 

GONORRHEA. 

The therapeutics of urethritis depends upon whether it is acute or 
chronic, and is modified by the seat of inflammation— a posterior 
urethritis not being amenable to the same treatment which cures 
the disease in the penile portion of the urethra. 

The membranous and prostatic portions of the urethra constitute 



GONORRHEA 795 

its posterior part. They are surrounded by layers of powerful 
muscles which play the part of vesical sphincters. Hence, hand 
injections usually pass to, but not beyond, its membranous part, 
and are useless if administered with the intention of combating 
inflammation of the posterior urethra. Gonorrhea is rarely con- 
fined to the anterior urethra. A common cause of gleet is the omis- 
sion of measures calculated to cure the deep inflammation. 

Bactericides, used at one time because of this quality, and on the 
theory that what can be accomplished by them in the culture tube 
is indicative of what can be expected of them when applied to an 
infected urethra, depend for their value in part only upon their 
bactericidal power, since they reach only the surface, and are futile 
against deep infections. Their major value depends upon the 
degree of inflammatory reaction excited by them. 

The prophylaxis of gonorrhea is comparatively simple. In the 
female mediate contagion occurs, and in girl babies is frequent. It 
can be avoided by cleanliness. 

Immediately following exposure, urination, momentarily inter- 
rupted several times by closing the meatus with the finger, a thorough 
washing of the glans penis and prepuce with soap and water, and 
an instillation of 20 drops of a 5 per cent, freshly prepared protargol 
solution into the open lips of the meatus, by means of an eye-dropper, 
will usually prevent the development of gonorrhea, even though 
gonococci have been deposited on the meatal surface. 

When the symptoms of infection have developed, providing 
treatment be instituted before there has been deep penetration by 
the gonococci, destruction and elimination of the infection is still 
possible. When a patient presents himself within a few days of 
exposure with a slight discharge, made up in the main of squamous 
epithelium and showing gonococci, he is given a three-ounce bottle 
of a 5 per cent, solution of protargol (freshly prepared), and is directed 
to inject by means of a cone-nozzled urethral syringe the first three 
inches of his urethra every two hours during the day and twice at 
night, urinating first in each instance and dropping a few drops into 
the open lips of the meatus before making the injection. The injec- 
tion is confined to the meatal three inches by pressing the penis at 
or behind the peno-scrotal juncture between the little and ring 
fingers of the holding hand. When the bottle of protargol solution 
is half empty it is filled with distilled water, this refilling being 
repeated as required for five days. The desired degree of inflam- 
matory reaction is characterized by a thin, slightly blood-stained 
serous discharge; there should be no severe pain after the first injec- 
tion or other sign of hyperacute inflammation. The gonococci 
usually disappear in the first twenty-four hours. After five days, 
even in the absence of gonococci, there may persist a slight muco- 
purulent discharge, best treated by astringent injections. 

When the patient presents himself with a frankly purulent dis- 



796 DISEASES 

charge teeming with gonococci, the treatment may be general or 
local— a combination gives the best results. 

The constitutional treatment always indicated has for its end: 

1. The best obtainable condition of general health, since cure, 
though helped by medicaments, is dependent on tissue resistance. 

2. An unirritating condition of the urine. This implies bodily 
quiet, perfect digestion, regular evacuations from the bowels, and 
a urine reaction neither strongly acid nor the reverse. 

3. The avoidance of local congestion. Constipation, sexual excite- 
ment, bodily fatigue, alcohol, and surface chilling are the common 
factors which produce local congestion. 

4. Free diuresis. Water drinking short of the extent which would 
interfere with gastric digestion. Milk or buttermilk diet. 

5. Drugs which in their elimination render the urine antiseptic 
and stimulating. These must be given with caution, and never to 
the extent of lessening the appetite or irritating the kidneys. Salol, 
uro tropin, santyl, copaiba, phenyl salicylate— these properly used 
are distinctly helpful. An excellent formula for the administration 
of balsam is the following: 

I$— Olei santali gr. v (0.3) 

Balsami copaiba? TTlv (0.3) 

Olei cinnamomi TTlj (0.06). — M. 

Pone in capsulam No. i. 
S. — These capsules should be taken one hour after meals, from 3ix to twelve being 
administered a day. 

The Lafayette or compound copaiba mixture still retains a popu- 
larity incident to its beneficial effect: 

1$ — Copaiba? §j 

Liquor hydroxidi potassse f3ij 

Fluidextracti glycyrrhizae f 5 ss 

Spiritus setheris nitrosi f §j 

Syrupi acaciae f5vj 

Olei gaultherise gtt. xvj. — M. 

S. — One tablespoonful after each meal. 

When internal treatment is depended upon entirely, the dosage 
is inversely proportionate to the intensity of the inflammatory 
reaction— indeed, this principle applies both to the general and the 
local treatment. 

Local Treatment.— An infected urethra may be treated either by 
irrigation or injection. The irrigation may be accomplished by a 
fountain-syringe and either a short nozzle or a catheter, or by a large 
piston syringe and a catheter. 

Irrigation.-— The choice of lotion is of minor importance. The 
familiarity of the surgeon with the degree of inflammatory reaction 
he may fairly expect from the lotion of his choice is of major import- 
ance. 

A satisfactory treatment consists in thoroughly and repeatedly 
flushing the urethra with permanganate lotion. This may be 



GONORRHEA 797 

accomplished by means of a fountain-syringe and a blunt, flattened, 
conical nozzle of such size that when its extremity is passed into 
the meatus its sides will be grasped so tightly that gentle pressure 
upon the nozzle will prevent regurgitation of fluid. The bag is 
filled with hot permanganate solution, 1:6000, and is elevated six 
feet above the level of the bladder. After first thoroughly washing 
the glans and lips of the meatus the nozzle should be inserted and 
held firmly in place until the entire anterior urethra is distended, 
when the nozzle should be slightly withdrawn and the urethral 
contents allowed to escape. After this has been repeated several 
times the nozzle is held firmly in place until 3 or 4 ounces of solution 
have passed into the bladder. This treatment should be repeated 
night and morning for at least a week, the strength of the perman- 
ganate solution being gradually increased up to 1:2000, if undue 
irritation is not caused by such increase. If at the end of a week 
no gonococci can be found, the irrigations should be continued once 
daily for four days, supplemented by astringent injections. When 
gonococci persist, the irrigations should be continued for two or 
three weeks. 

Injections.— When this method of irrigation cannot be practised, 
a syringe with a conical nozzle and with a capacity of at least 1 
ounce may be employed; this should be used two to six times a day, 
two syringefuls of the dilute lotion being injected immediately after 
urination. The liquid should be forced in very gently, being allowed 
to flow out by slightly lessening the pressure of the nozzle upon 
the meatus when the anterior urethra is full. When large injections 
are attempted by the ordinary small urethral syringe, the frequent 
application of the latter to the meatus occasions much irritation. 
It is desirable that the injections should pass back into the posterior 
urethra, since this portion of the canal is usually involved in acute 
inflammation. 

A hyperintense reaction, as evidenced by marked swelling and 
increase in pain and ardor urinse, indicates lessening the strength of 
medication and the frequency of application. 

The syringe of choice should have a conical nozzle, and an efficient 
and smoothly working piston. Urination always precedes injection. 

The following prescriptions used as hand-injections are among 
the most efficacious in checking persistent discharge: 

1$ — Nargol, argyrol, vel protargol gr. iij (0.2) 

Aqua? destillatse giij (90.0). — M. 

Or, 

1$ — Fluidextracti hydrastis (colorless) . . . . f 3iv (16.0) 

Bismuthi sublactatis 5vj (24.0) 

Glycerini f5iv (16.0) 

Aquae destillatse q. s. fSvj (180.0).— M. 

1$ — Zinci sulphatis gr. xx (1.3) 

Plumbi subacetatis gr. xv (1.0) 

Aqua? camphorae f 5j (30.0) 

Aquae destillatse q. s. ad f5vj (180.0).— M. 



798 DISEASES 

When injections are intensely painful, or their use following the 
immediate discomfort is not attended by a local feeling of better- 
ment in acute cases, they are probably doing more harm than good. 
This point is determined by withdrawing them for a day or two, 
or substituting for the medicament hot normal salt solution. 

When the gonorrhea has already assumed a markedly inflamma- 
tory type, with swelling and edema of the penis, redness and ever- 
sion of the meatus, and great sensitiveness of the urethra, and 
seems to be aggravated by mild irrigations, the* penis should be 
wrapped in cloths kept wet with dilute alcohol or lead-water and 
alcohol. With the subsidence of acute inflammatory symptoms and 
the appearance of copious discharge the injection treatment may be 
inaugurated. It must be remembered that injections may in them- 
selves prevent the discharge from entirely disappearing. Hence, 
as the symptoms ameliorate the injection should be made less fre- 
quently, finally being entirely omitted for some days if the discharge 
seems to continue longer than usual. 

Obstinate chordee may require bromide of potassium and chloral. 
Of these a dram of the former must be given at bedtime, and 10 
grains (0.6) of the latter; this may be repeated in the night if pain- 
ful erections persist. Opium or belladonna suppositories, or hypo- 
dermic injections of morphine, gr. \ (0.015), and atropine, gr. eV 
(0.001), will prove satisfactory. The patient should be instructed to 
take a prolonged hot bath before going to bed, and to rise during 
the night to pass water. 

Ardor urinse is usually relieved by the use of demulcent drinks and 
by the employment of bicarbonate of sodium or citrate of potassium 
in sufficient doses to render the urine but slightly acid. Either of 
these drugs is conveniently administered in the form of compressed 
tablets, taken one or two hours after meals in 10-grain (0.6) doses 
with plenty of water. The instillation into the urethra, by means of 
an eye-dropper, of a 4 per cent, solution of cocaine a few minutes 
before urination markedly diminishes the burning. Finally, this 
symptom may often be relieved by instructing the patient to pass 
water with the penis submerged in a vessel containing hot water. 

Where the inflammation is of a high grade and attended by fever 
and general malaise, rest in bed, milk diet, and the administration 
of 6 minims (0.4) of tincture of aconite, repeated every two or three 
hours, is followed by marked relief. 

The distressing symptoms of acute posterior urethritis do not 
usually develop until the disease of the penile portion of the urethra 
has run a course of two or three weeks. During the very acute 
symptoms local treatment applied to any portion of the urethral 
canal probably aggravates the condition, and even the internal 
administration of balsams and antiseptics must be employed with 
very great caution if at all. Hence, when in the third week of 
gonorrhea frequent urgent and painful micturition indicates, an 



GONORRHEA 799 

acute exacerbation of posterior urethritis, suspension of all active 
treatment is indicated. The bowels are kept open; the diet is 
carefully regulated; the urine is rendered bland, unirritating, and 
antiseptic; repeated warm baths are ordered, the painful symptoms 
being controlled by opium and belladonna. When the acute symp- 
toms subside, the quantity of antiseptics taken by the mouth may 
be increased, balsams may be added, and local treatment may be 
directed first to the posterior urethra, after the cure of which the 
anterior urethritis should receive attention. It has been stated 
already that injections forced into the meatus rarely penetrate 
beyond the bulbous portion of the urethra; hence to influence the 
deeper portions of this canal some other method of applying drugs 
must be devised. This end is best accomplished by means of the 
gravity-bag and short conical meatus nozzle or the instillator. 

The use of the instillator is indicated when total flushings are 
unavailing. 

The patient is first instructed to empty the bladder of a portion of 
its contents; by this means the urethra is flushed out. The anterior 
urethra is then irrigated by means of the bag and short nozzle, after 
which the instillator is passed until its tip has entered the membran- 
ous urethra. From ten to twenty drops of the solution of choice 
are then injected, and in their backward flow bathe the entire mem- 
branous and prostatic urethras. Protargol, 0.5 per cent., or silver 
nitrate, 0.1 per cent., are the medicaments of choice. The treat- 
ment should be repeated every third day, and should be preceded 
by gentle prostatic massage. Instillation may be given through a 
catheter passed until its eye reaches the prostatic part of the urethra. 
By means of a syringe the injection of choice then can be driven in. 
This fluid enters the bladder, and is passed with the urine at the 
next act of micturition. 

Chronic Gonorrhea. 

Chronic gonorrhea differs from the acute form in the fact that 
the inflammation is distinctly localized in certain portions of the 
urethra, and does not invade the whole canal with uniform intensity ; 
hence, efficient treatment must be directed not to the whole urethra, 
but to the diseased areas. Foci of chronic urethritis are usually 
found either in the bulbous portion of the urethra or in the mem- 
branous or prostatic portion. If the disease is located in the anterior 
urethra, it will commonly be found to depend upon the existence 
of a stricture of large caliber. The passage of sounds of full size— 
cutting the meatus if this is necessary for their introduction— will 
be followed by prompt relief in such cases. The sounds should be 
used not more frequently than twice a week, and should be preceded 
by mild antiseptic irrigation, best effected by the gravity-bag and 
short urethral nozzle, irrigating daily with silvol, argyrol, or pro- 



800 DISEASES 

targol (1:3000 to 1:500), silver nitrate (1:5000), mercurol (1:2000), 
or potassium permanganate (1:2000 to 1:500). When the general 
catarrhal condition is materially modified, by means of an ordinary 
urethroscope, the focus of inflammation may be exposed, and may 
be treated directly by strong astringent solutions carried in by 
means of a brush or by absorbent cotton secured to the extremity 
of a long applicator. Nitrate of silver or sulphate of copper, 20 
grains to the ounce (1.3-30.0), may be employed. Unna has devised 
a most successful treatment for obstinate cases of gonorrhea. He 
advises coating the sounds with the following mixture: 

I$— Olei cocse giij (90.0) 

Cerse flavi 3ss (2.0) 

Argenti nitratis gr. xv (1.0) 

Balsami Peruviani 3ss (2.0). — M. 

This is liquefied in a water-bath; the sounds are dipped in it and 
are then hung up to dry. On being passed the heat of the body 
melts the coating. Practically their employment is often followed 
by brilliant results. This formula should be prepared by the follow- 
ing plan: Rub the balsam of Peru in a mortar with 20 drops of 
diluted alcohol to thin it. Dissolve the silver nitrate in about 15 
drops of distilled water and add with constant stirring to the balsam 
solution until it is a uniform mixture. To this add gradually with 
constant stirring the cocoa butter and yellow wax previously melted 
together on a water-bath and allow to congeal. 

Chronic posterior urethritis must be treated by remedies applied 
directly to the diseased area. The silver salts are more commonly 
successful than any other medication. By means of Ultzmann's 
instillator 5 to 10 minims (0.3-0.6) of a solution varying in strength 
from 0.1 per cent, to 5 per cent, may be employed. Irrigations are 
also serviceable; but previous to their employment the prostatic 
follicles should be emptied of their purulent contents by massage 
through the rectum. 

Finger recommends the following ointment: 

1$ — Argenti nitratis vel cupri sulphatis gr. xv (1.0) , 

Lanolini giij (90.0) 

Olei olivse 3iss (6.0). — M. 

By means of an ordinary catheter— which is first filled, then intro- 
duced until its eye reaches the prostatic portion of the urethra— a 
definite quantity of the ointment can be forced into the canal by 
a graduated rod. 

Frequently the therapeutic influences of cold, together with 
pressure, are found beneficial. The best means of combining these 
two remedies is found in the psychrophore, an instrument in the 
shape of a sound, but so arranged that a stream of water flows through 
its interior. 

It must be borne in mind that chronic gonorrhea is commonly due 
to unskilful or not sufficiently prolonged treatment of the acute 



GONORRHEA 801 

stages. Xot only should the treatment of acute gonorrhea be con- 
tinued until the gonococci have entirely vanished, but for fully two 
weeks after the disappearance of all symptoms of inflammation. 
The same rule holds good in regard to the chronic manifestations of 
the disease. 

Per contra, it must not be forgotten that long-continued irritant 
treatment may in itself indefinitely prolong a urethral discharge. 

There is a mucous secretion which quite frequently follows a gon- 
orrhea, but which is in no way dependent upon the persistence of 
this disease. Microscopic examination will at once determine its 
nature. It is probably most rapidly cured by attention to general 
hygiene and by tonic and supporting treatment. 

A urethritis due to the Micrococcus catarrhalis which exhibit 
the staining reactions of the gonococcus and can be distinguished 
from the latter only by cultural studies, differs from gonorrhea only 
in the comparative mildness and brevity of the untreated course. 
It recovers in from two to four -weeks without treatment and almost 
as quickly if treated not too vigorously. 

Complications of Gonorrhea. 

Balanitis and balanoposthitis are treated by perfect cleanliness. 
The discharge must be thoroughly washed out, and the surface 
must be dried and isolated. The thorough cleansing of the parts 
is best accomplished by weak astringent solutions, such as the 
chloride of zinc, 4 grains to the ounce (0.25-30.0), 1 per cent, 
boric acid, or 1.5 per cent, phenol; nitrate of silver is particularly 
valuable, and in the proportion of 1 grain to the ounce (0.06-30.0) 
will be found sufficiently strong for use as a wash or injection. The 
superficial ulcerations may be further touched with the solid stick 
of the nitrate of silver. The prepuce having been retracted and 
the parts thoroughly washed, dusting-powder, such as tannin or 
oxide of zinc, is distributed over the surface of the inflamed parts; 
the glans is then covered with a thin layer of absorbent cotton and 
the prepuce drawn forward. This dressing is to be repeated three 
times daily. 

If the phimosis is so tight that the prepuce cannot be retracted, 
cleansing, astringent injections, and wrapping the penis in one or 
two thicknesses of gauze or other thin fabric, constantly kept wet 
with dilute lead- water, will be the treatment indicated. If, in spite 
of this treatment, inflammatory symptoms become more marked, 
splitting the foreskin or circumcision is indicated. 

Prostatitis is a rare complication, and in its early course presents 
the symptoms of posterior urethritis. Where the acute symptoms 
are fairly developed direct local treatment is of little avail. Rest 
in bed, light diet, careful regulation of the bowels, medication to 
render the urine bland and unirritating, elevation of the pelvis, 
51 



802 DISEASES 

prolonged hot baths, rectal ice-bags, and the administration of 
morphine and belladonna, either by means of suppository or by 
hypodermic injection, represent the general treatment of all inflam- 
matory conditions at or about the neck of the bladder. In the great 
majority of cases prostatitis undergoes prompt resolution, and this 
is more powerfully influenced by rectal irrigation than by any other 
method of treatment. For this purpose a two-way rectal tube 
must be employed, the nozzle of which is directed against the pro- 
jection of the prostate into the bowel. From 2 to 4 quarts (2 to 4 
liters) of normal saline solution, either very cold or as hot as can be 
borne, are allowed to flow into the rectum by gravity, this arrange- 
ment of the tubes allowing an injection to flow out as rapidly as it 
flows in. This treatment should be repeated three or four times a 
day. When, in spite of careful treatment and the free use of ano- 
dynes and antispasmodics, there is retention of urine, a soft catheter 
should be passed into the bladder and allowed to remain there. 

If general and local symptoms denote abscess-formation, the pus 
should be evacuated by perineal incision as soon as its definite 
location can be determined. It is true that the pus collection 
usually is spontaneously discharged into the urethra, but this result 
cannot certainly be depended upon, and, at best, is an unsatisfactory 
termination of the trouble. 

When the inflammation runs into a chronic type, the treatment 
suitable for chronic posterior urethritis is indicated— namely, the 
use of large cold steel sounds, massage, and local applications to 
the prostatic urethra. In addition, rectal injections, by means of 
the two-way tube, are very efficient in relieving symptoms. 

Epididymitis as a complication of acute urethritis usually develops 
in the third week of the disease incident to overactive local treat- 
ment, sexual excitement, bodily activity, dietetic error, or con- 
stipation. In its hyperacute form it is attended by pain of crippling 
intensity, confining the patient to bed. 

The testicles should be supported by a handkerchief bandage, the 
base of which is passed beneath the scrotum, while the ends and 
apex are secured in front to a circular band passing about the waist. 
To combat the agonizing pain saturated solution of magnesium sul- 
phate is employed or a 5 per cent, guaiacol ointment. These or 
other applications usually must be supplemented by hypodermic 
injections of morphine. Puncture with a tenotome is, in case of 
excessive swelling, at times advisable, or in hyperacute cases free 
incision and drainage. This when the local and constitutional symp- 
toms of pus under tension are progressive. During the period of 
acute inflammation local treatment to the urethra is contraindicated. 

On the subsidence of the acute inflammatory symptoms confine- 
ment to bed is no longer needful, providing the testis is properly 
supported by a suspensory bandage. This must be so arranged 
as to apply uniform pressure and at the same time exert the resol- 



GONORRHEA 803 

vent influences of heat and moisture. This end is attained by 
enveloping the entire scrotum in a thick sheet of absorbent cotton 
or of lambs' wool, applying over this a sheet of rubber dam and, 
finally, a properly fitted elastic jock-strap. The gauge as to the 
efficacy of this dressing is the comfort it affords. 

When the acute symptoms have disappeared attention must be 
directed to the removal of infiltration, which if it persists may be a 
cause of sterility. This is accomplished by the continuance of heat, 
moisture, and pressure; by local applications, such as iodine gr. iv 
(0.25) in lanolin §j (30.0), or of equal parts of mercury ointment 
and belladonna ointment, or by ichthyol, with lard, half and half, 
and by the internal administration of iodide of potassium, 3 to 5 
grains (0.2-0.3) three times daily. 



Gonorrhea in the Female. 

The symptoms of acute gonorrhea in the female are usually so 
mild that the attention of the physician is rarely called to the disease 
until it has reached its chronic form and has invaded the uterus and 
its appendages. When, however, acute urethritis is found, the treat- 
ment, both local and general, is conducted on the same principles as 
when the disease attacks the male urethra. During the most acute 
stage no local treatment is advisable, but subsequently injections 
can be made with the ordinary hard-rubber syringe, not more than 
a dram and a half of the liquid being employed at a time. If the 
urethral discharge persists, the seats of the suppuration are readily 
found by the endoscope tubes, and treated directly by applications 
of strong solutions of nitrate of silver or sulphate of copper. The 
results of treatment are commonly satisfactory. 

Acute vaginitis is not very frequently observed, excepting in 
infants and young girls. In addition to the general treatment of 
inflammation, local treatment directed to cleansing thoroughly the 
inflamed surfaces of discharge and acting upon them by a strong 
antiseptic lotion is indicated. The patient is instructed to irrigate 
the vagina three times daily with 2 pints (960 cc) of bichloride- 
of-mercury solution, 1:4000, thrown in by means of a fountain 
syringe. For this fluid to reach every portion of the diseased mucous 
membrane it is necessary that the patient should lie upon her back 
with the hips elevated. Before rising a pledget of absorbent cotton 
is placed between the labia. During the most acute stage of vagi- 
nitis hot saline injections and prolonged hot sitz-baths are indicated. 
In addition to the antiseptic irrigations which the patient is directed 
to make, the physician should every second day insert a speculum 
and paint every portion of the diseased mucous membrane with 
nitrate-of-silver solution varying in strength from 4 to 40 grains to 
the ounce (0.25-2.6:30.0). The vagina should then be packed with 



804 DISEASES 

tampons of absorbent cotton, which may be dusted with astringent 
medicaments. 

Vulvitis corresponds to balanitis in the male, and is treated in a 
similar manner. Cleanliness is the most essential point in securing 
a cure. The parts are thoroughly washed with weak antiseptic 
lotions, and the abraded mucous surfaces are kept from coming in 
contact by means of a piece of sterile gauze soaked in mild astringent 
solution. Vaccine treatment is indicated for chronic gonorrhea. 

GOUT. 

Gout is a word used to signify a series of manifestations occur- 
ring chiefly in those who have led an inactive life devoid of exercise, 
have lived on the fat of the land, and partaken more frequently of 
alcoholic beverages than of water; or it occurs in persons who do not 
live in this way, but whose ancestors have done so, and have trans- 
mitted to them the gouty taint or diathesis; or, once more, in those 
who have had poor food for a long time. In other words, it is a 
disorder of nutrition and metabolism. Very few Americans have 
gout in its marked and characteristic forms, owing to the active 
life they pursue, and to the fact that the inhabitants of the Western 
hemisphere drink large amounts of water, thereby continually dis- 
solving effete matters in the system and washing them away. Never- 
theless many Americans suffer from what may be called lithemic 
symptoms, which are due to lack of exercise, overeating, and perverted 
metabolism. 

The therapeutic importance of pure water in this state is remark- 
able, but the so-called lithia waters depend for their value more 
upon their freedom from lithium salts than upon their presence. 
When a patient goes to medicinal springs, by continually drinking 
water he washes out the kidneys and prevents deposits of effete 
matters throughout the body. In a gouty individual the liquids 
of the body may be said to be so overladen with salts that they 
deposit them wherever a spot is found which is easy of access, just 
as water laden with lime forms a deposit on the sides of its bed in 
times of drought and dissolves and removes these formations when 
a freshet takes place. Very often, when pure waters are not attain- 
able, satisfactory results will be obtained from ordinary distilled 
water, the insipid taste of which can be overcome by charging it 
with carbonic acid gas. 

When an acute attack of gout comes on, it is generally situated, 
as is well known, in the joint of the big toe, but it may involve any 
part of the body, even to the heart and the abdominal viscera. By 
far the best remedy for the relief of the pain, if it is unbearable, is 
morphine, which should be given hypodermically. At the same 
time the best remedy for gout that we have, colchicum, should be 
freely given until the patient shows the full effect of the drug, as 



GOVT 805 

evidenced by gastro-intestinal discomfort or pain and slight laxity 
of the bowels. The drug should be used in the form of the wine of 
the seed, in the dose of 40 minims (2.6) at first, and increased by 
2 minims (0.12) every four hours until relief is obtained or symp- 
toms of overdose appear as noted above. In other instances the 
method of administration suggested in the article on Colchicum 
may be resorted to. 

Many physicians at the present time prefer the somewhat more 
agreeable method of using colchicum in the form of colchicine salicy- 
late, which is a mixture of colchicine and oil of gaultheria, about 
i+o grain (0.0006) of colchicine being present in each capsule and 3 
to 6 being given each day, at intervals of a few hours. 

The local treatment of gout, when it is active, consists in the 
application of a number of remedies. For hospital practice a very 
useful mixture is made by adding 1 part of bicarbonate of sodium 
to 9 parts of linseed oil. The joint is then wrapped in a piece of 
lint soaked with this concoction. In other cases collodion may be 
applied in one or two good coats, not more, with relief, and in still 
others oil of peppermint has been recommended. It is to be remem- 
bered, however, that the inflamed joints are not to be treated by 
depletion through leeches or bleeding, as by this means they ulti- 
mately become worse; or, in other words, the treatment of gouty 
inflamed joints is not identical with that of inflamed joints from 
other causes. When the pains of acute gout are very severe at 
night, potassium iodide, in the dose of 15 grains (1.0) at four or 
five o'clock in the afternoon, will sometimes give relief; this drug 
should always be combined with colchicum if the disease is subacute 
or chronic. 

In chronic gout, except during the acute exacerbations of the 
disease, colchicum is almost useless, but potassium iodide should 
be pushed to the point of iodism if the trouble be painful. Here 
diet forms an important part of the treatment, and should consist 
of foods which are not fatty nor rich, but plain and nourishing. 
Milk and eggs, the white meat of chicken, and fruits, cooked with- 
out sugar being added, are allowed, tea and coffee being used only 
in moderation. If any wine is taken, it must be followed by copious 
draughts of pure water, and this last article should be used ad libitum. 
On the other hand, pastries, and, more than all, sweet wines, are 
the worst things that such a patient can take, and must be absolutely 
prohibited. 

The insomnia of chronic or subacute gout is best overcome by 
strontium bromide and chloral, the former drug being the safest 
and best. Barbital or barbital sodium are also useful. 

Nothing should be done in the neighborhood of gouty joints which 
will injure the skin, as it is easily disorganized and its injury may 
lead to erysipelas. Where the deposit around a joint is very great 
and the normal movements are impossible, relief is often obtained 



806 DISEASES 

by the application of a solution of citrate or carbonate of lithium, 
5 to 10 grains to the ounce (0.3-0.6:30.0) of water, on lint 
wound around the parts. Where the skin is broken and will not 
heal, this treatment often permits healing by dissolving the crystals 
in the wound which prevent approximation of the edges and cause 
local irritation. 

Iodine ointment, or the tincture of iodine, is often placed around 
chronic gouty joints with advantageous results. 

A standard remedy in subacute or chronic gout is arsenic, and its 
administration in the form of 3 minims (0.2) of Fowler's solution, 
with either perfectly pure or lithiated water, is always to be resorted 
to when the iodides and colchicum are temporarily abandoned. If 
anemia is present, arsenic is particularly indicated, and cod-liver 
oil and syrup of the iodide of iron are also of value in this state. 
Gouty patients should take as much exercise and be in the fresh 
air and sunshine as much as possible. 

We find, therefore, in conclusion, that the use of large amounts 
of pure water free from salts, and the administration of colchicum, 
potassium iodide, and arsenic are the greater points about which 
treatment should center. In those cases where retrocedent gout 
occurs the heart must be supported by stimulants, particularly by 
hypodermic injections of ether, until the slower drugs can act, by 
heat over the belly, by the use of opium to allay irritation, except 
when the brain and kidneys are seriously affected, by the use of 
diuretics and alkaline drinks, and finally by counterirritation in the 
shape of a mustard plaster placed over the abdomen or chest as the 
case may require. 

HAY FEVER. 
(See Pollen Proteins, Part III.) 

HEADACHE. 

(For Neuralgic Headaches, see Neuralgia; for Bilious Headache, 
see Biliousness.) 

Probably no single source of pain compares in its frequency to 
headache, chiefly because it is essentially a symptom of many dis- 
ease processes or functional disturbances. It may arise from con- 
stipation or eye-strain, from brain disease, from anemia, from uremia, 
from plethora, from nervous breakdown, and from a multitude of 
causes which, if they were all recounted, would cover many pages of 
this book. 1 In many instances the employment of a mild laxative, 
which will cause the bowel to empty itself thoroughly, is a necessity. 

1 See chapter on Headache in the author's Symptoms in the Diagnosis of Disease, 
8th ed. Lea & Febiger. 



HEADACHE 807 

In others a careful measurement of the amount of urine passed in 
the twenty-four hours will show that the urinary secretion is defi- 
cient in liquids and solids, so that effete and poisonous materials are 
retained in the blood, which produce headache. For such cases, if 
the urine is acid, the frequent use of Vichy water (Celestins Spring), 
to which is added a little bicarbonate of potassium as a diuretic, 
will prove of great service. If the urine is alkaline, 10-grain (0.6) 
doses of ammonium benzoate three times a day are often useful. 

Congestive headaches, dependent upon engorgement of the cere- 
bral vessels with blood, are to be treated in a number of ways. If 
any direct cause of congestion can be discovered, this must, of course, 
be removed. So far as the direct application of drugs is concerned, 
we find two methods of promoting a cure, according to the cause. 
Thus, if the patient be neurasthenic and feeble, the use of ergot and 
strychnine, which will cause contraction of the dilated vessels, is 
useful; whereas if the congestion is due to high arterial tension and 
excessive cardiac action, the bromides and the employment of 
vascular sedatives, such as nitroglycerin and aconite, which will 
produce arterial depression and so remove congestion, are indicated. 
It is to be remembered that when the congestion is due to vascular 
relaxation and weakness vascular sedatives are contraindicated. 

The use of a hot mustard foot-bath is of great value, and a mus- 
tard plaster or dry cup applied to the nape of the neck is often of 
service in congestive headaches, while in severe cases an ice-bag 
applied to the head or leeching behind the ears or on the temples 
may be resorted to. Bleeding often gives relief at once in severe 
congestive headache. 

In nervous women who suffer from headache much comfort and 
relief will often ensue if the top of the head be wet with one of the 
following formulae: 

1$ — Spiritus camphorae f 5J (30.0) 

Spiritus lavandulae, 

Alcoholis aa f §ij (60.0). — M. 

S. — Apply locally. 

Or, 

1$ — Camphorae, 

Olei menthae piperita? aa 5J (4.0) 

Chloroformi f 5ss (16.0) 

Alcoholis q. s. ad fgiij (90.0). — M. 

S. — Shake the bottle and apply a little of the liquid to the head. 

In other instances bathing the head with cologne-water to which 
have been added 5 grains (0.3) of menthol to the ounce is useful. 

Where headache depends upon fatigue, either general or local, 
stimulating treatment is necessary. If eye-strain be the cause, full 
doses of strychnine or mix vomica are of service, but these remedies 
cannot be used if there is much retinal irritability. Proper eye- 
glasses are, of course, indicated in such a case. 



808 DISEASES 

In many instances a combination of caffeine, bromide of potassium, 
and antipyrine is very successful, as follows: 

fy — Caffeinse citratae . . . gr. xl (2.6) 

Potassii bromidi 5iv (16.0) 

Antipyrinae 3ij (8.0). — M. 

Fiant chartulse, No. xx. 

S. — One powder in water as needed. 

Sometimes the caffeine makes the headache more acute, and if 
this occurs only the antipyrine and bromide can be used. (See 
articles on Antipyrine, Acetanilid, Cannabis, Gelsemium, and Acet- 
phenetidin (Phenacetin) .) 

Another useful prescription is: 

1$ — Extracti guaranae gr. x vel xx (0.6-1.3) 

Extracti apii graveolentis gr. x (0.60). — M. 

Fiant in capsulas vel chartulas vel pilulas No. x. 

S. — One every half-hour until relieved or three are taken. 

Sleep is generally a more useful prescription than any drug, and 
if city life creates so much mental anxiety during the day as to be 
wearing upon the nervous system or make the patient wakeful at 
night, business must be put aside and health and recreation sought 
at a watering-place. Horseback exercise is very useful indeed, and 
should be resorted to by all who can afford it if they are sufferers 
from nervous headaches Walking is also useful. 

A form of headache which is often very severe, sometimes fleet- 
ing, sometimes persistent, is that due to gout, and it is to be treated 
by means quite distinct from those named so far. Some practitioners 
of wide experience employ salicylic acid in doses of from 5 to 15 
grains (0.3-1.0), while others rely on the iodide or acetate of potassium. 
(See Migraine.) Aspirin in 10-grain (0.65) doses is very useful. 

Other cases of a gouty headache require colchicum, particularly 
if the gout be widely distributed in its manifestations, and to these 
Hamilton gives: 

1$ — Vini colchici seminis f 5ss (16.0) 

Potassii acetatis 3v (20.0) 

Potassii iodidi 5v (20.0) 

Tincturae cimicifugse f5v (20.0) 

Aqua destillatse q. s. ad f giv (120.0).— M. 

S. — Teaspoonful (4.0) every four hours. 

In cases in which anemia is associated with the gouty tendency 
Peabody uses the following prescription, the ingredients of which are 
compatible, whereas most of the preparations of iron and salicylic 
acid are incompatible: 

1$ — Acidi salicylici gr. xx (1.3) 

Ferri pyrophosphatis gr. v (0.3) 

Sodii phosphatis gr. j (0.06) 

Aquse destillatse f5ss (16.0).— M. 

S. — To be taken every three hours. 



HEART DISEASE 809 

Cohen has used the following, which is more pleasant to the taste: 

3— Sodii salicylates 3iv (16.0) 

Glycerini fgij (60.0) 

Olei gaultheriae lUxx (1.3) 

Tincturae ferri chloridi f 3iv (16.0) 

Acidi citrici gr. x (0.6) 

Liquoris ammonii citratis, B.P. 1 . . q. s. ad f 5iv (120.0). — M. 

S. — Dessertspoonful (8.0) in water twice, thrice or four times a day. 

(For the treatment of migraine, see Migraine.) 

HEART DISEASE. 

(For Treatment of Angina Pectoris, see p. 679.) 

The writer classifies all forms of heart disease under this heading 
advisedly. In valvular disease the profession understands more and 
more that the mere destruction or laming of this valve or that has 
little to do with the treatment although, the ultimate result of the 
case is somewhat dependent upon these conditions. It matters not 
whether the leak in a valve be minute or great, provided the heart 
can still do its work; the condition of the cardiac muscle is the import- 
ant factor to be considered. If an irreparable leak exists in a 
pump which cannot be stopped for repairs, the question is not, Can 
we cure that leak? but rather whether we can work the pump with 
enough force and rapidity to obtain all the water needed for the 
maintenance of life. Some physicians use heart tonics, such as 
digitalis, whenever they find a valve diseased, as if to mend the broken 
valve. - Nothing can be more erroneous, for a valve once injured is 
never regenerated. It is only in those cases which have relaxation 
of the muscular fibers around the orifice that digitalis can cure a 
murmur of mitral regurgitation. 

It should be an invariable rule with every physician in examining 
a patient with heart disease to determine whether or not the tissues 
of the body receive their normal blood-supply. If they do not, even 
though the leak is so small as almost to escape notice, treatment is 
to be instituted; but, on the other hand, if the murmur heard on 
auscultation is as loud as that of a machine-shop and the tissues 
are not starved, no remedy is needed. Indeed, it not rarely occurs 
that no murmur can be heard in the presence of signs of circulatory 
feebleness, because the heart may be too feeble to drive the blood 
past the leaking valve with sufficient force to produce any sound. 

Another very important point in regard to the treatment of 
cardiac disease in children is the remembrance that the stunting of 
the body and the slowness of growth are not merely the result of 

1 Liquor ammonii citratis, B. P., is made by adding 5 fluidounces (imperial measure) 
of strong solution of citrate of ammonium to 15 fluidounces (imperial measure) of dis- 
tilled water. The stronger solution of citrate of ammonium is made by taking 12 
ounces (avoirdupois) of citric acid, strong solution of ammonia 11 fluidounces, and 
adding enough distilled water to make 24 fluidounces (imperial measure). 



810 " DISEASES 

heart trouble, whereby the tissues do not increase in size from lack 
of nourishment, but occur for a special purpose. Let us suppose 
that a child of eight or nine years has scarlet fever or rheumatism, 
which leaves the cardiac valves impaired in function, the question 
must arise, "Can the heart properly fill the bloodvessels? " If the 
heart can supply the vessels, the child lives, but is stunted, because 
Nature is wise enough to understand that the struggling heart has 
all it can do to supply even a stunted frame, and realizes that a 
rapidly increasing area of bloodvessel surface in a growing child 
would exhaust the cardiac muscle. 

The physician should not permit the parents to worry over this 
lack of growth, but by the use of gentle gymnastics or tonics, and 
attention to the general health, he is often enabled to improve the 
cardiac condition. As soon as this organ is strong enough to permit 
of growth, growth will take place. 

In the general treatment of heart disease the most important 
thing for the physician to prescribe is rest. A tired heart cannot 
supply an active body. A very definite idea of how fatigued the 
heart muscle is, or how much it has failed as the result of myocardial 
degeneration can be obtained by the stair-climbing test. If the 
heart is normal the blood-pressure rises under exercise, but if it is 
feeble the blood-pressure falls. So, too, if the difference between 
the diastolic pressure and the systolic pressure is low this is also 
indicative of a weak heart as a rule. 

Having made these preliminary remarks, let us turn to the direct 
application of drugs to heart disease, the chief drug in the list being, 
of course, digitalis. 

The value of digitalis may be said to rest upon a number of influ- 
ences possessed by it. In the first place, evidence is constantly 
accumulating to show that digitalis increases the nutrition of the 
heart muscle by the stimulating influence which it exerts on the 
pneumogastric nerve, this nerve having been partly proved to be 
a trophic nerve of the heart. Aside from any such nervous influ- 
ence, the heart muscle receives a greater blood-supply under the 
use of digitalis, since both diastole and systole are influenced by 
the drug, the systole being more complete and the diastole being 
prolonged and more extensive. 

Two theories concering the nutrition of the heart muscle through 
its blood-supply have been promulgated. One is, that the coronary 
arteries are filled with arterial blood as the heart drives its contents 
out of the left ventricle into the aorta, or, in other words, during 
systole. The other hypothesis rests upon the belief that the con- 
tracting muscle prevents a free circulation of blood through the 
cardiac bloodvessels, and that the blood is driven into the coronary 
arteries during diastole by the pressure in the aorta, the aortic valves 
being closed. The latter view is incorrect so far as the coronary 
arteries are concerned, for they are filled during ventricular systole, 



HEART DISEASE 811 

and this systolic contraction of the muscular fibers urges -onward the 
blood already in the intramural vessels. Nevertheless the complete 
passage of the blood through the smaller vessels of the cardiac mus- 
cle only takes place as relaxation or diastole occurs. The ground 
for this belief consists in the observation that a muscle when firmly 
contracted always presses upon its supplying bloodvessels, and 
partially interferes with capillary flow. The heart of one of the 
lower animals, if carefully watched after the chest- wall is removed, 
will always be found to become paler during systole and redder 
during diastole. As the blood everywhere in the body nourishes 
the tissues, not when in the arteries, but while passing through the 
capillaries, it would seem self-evident that, while the coronary 
arteries are filled by the systole or contraction of the heart, the 
nutritive changes and perfect capillary circulation go on during 
diastole. If these premises are true, the increase in cardiac nutrition 
and growth under the action of digitalis is only what one would 
expect, for we have learned when studying this drug that it prolongs 
diastole and increases the force and volume of the systolic wave of 
blood. In other words, digitalis fills the coronary arteries almost 
to bursting, and so, when diastole occurs, not only floods the cardiac 
capillaries with blood, but prolongs the period during which the 
interchange between the blood-stream and tissues takes place. 1 

The value of the regulating or inhibitory influence of the vagus 
has become more apparent with the advance made recently in our 
knowledge of the physiology of the heart. Thus it has been shown 
that in systole the heart muscle becomes refractory to stimuli and 
loses its irritability, contractility, and conductivity, all of which are 
restored during the diastolic pause. Further than this, the efficiency 
of the heart is apparently in direct ratio to the length of the pause, 
that is, of the period of resuscitation. Digitalis by stimulating the 
heart causes it to put forth more energy, and yet by prolonging 
diastole and slowing the rate rests the heart. 

Normally, the heart beats fast or slow according to the demands 
for blood made upon it by the system, and its action is varied by the 
calls which it receives from the tissues. In heart disease, with failure 
of compensation owing to leaky valves, the tissues are starved, and 
continually send messages for more nourishment to the cardiac 
muscle, which finally becomes exhausted by its endeavors to supply 
their wants, and beats faster and faster in its efforts to compensate 
for the leak. If digitalis is given, the vagi render the cardiac action 
regular and effective, acting as a regulator and director of its ener- 
gies, thereby supplying the tissues and using the remaining power of 
the heart to the greatest advantage, in addition to improving its 
blood-supply by the methods already described. The starving 
tissues of the body having been satisfied, as Wood has eloquently 

1 See article on Digitalis in Part II of this book. 



812 DISEASES 

expressed it, "the angry messengers from the periphery cease their 
callings, and the heart is at peace and in comfort." 

From what has been said it becomes evident that this drug (digi- 
talis) generally does good when the heart is feeble, and we find for 
this reason that cardiac dilatation, simple cardiac failure, or heart- 
failure dependent upon the presence of poisons, all indicate its use. 

The question to be asked the physician of himself when in the 
presence of a weak heart is What am I to try to do? If the heart 
is utterly fagged out as the result of the labor induced by valvular 
lesions the answer usually is to give one large dose of the tincture 
by the mouth, 1 to 2 drams (4.0-8.0), and wait for effects, giving 
much smaller doses later on to maintain the effect. So too, if auric- 
ular fibrillation is present such a course should be followed. If 
the heart is not utterly fagged but tired then doses varying from 
5 to 20 minims (0.3-1.3) of the tincture three times a day are all 
that is needed with rest or somewhat larger doses soon cut down. 
Before giving the very large doses, however, the physician must be 
sure that partial heart block is not present and that the patient 
is not already digitalized by another practitioner. (See article on 
Digitalis and Quinidine under Cinchona, Part II.) 

The mechanism of the action of digitalis in the different cardiac 
valvular lesions still remains to be described, but before doing so the 
author desires to remind the reader that a patient under the full 
influence of digitalis ought to maintain the recumbent posture. 
(See article on Digitalis.) Further, the effect of the drug tends to 
accumulate, and therefore it should be stopped for several days at 
the end of each week of its use when it is given in full doses. 

Taking up the most common condition, that of mitral regurgita- 
tion, we find that in this disease the blood passes, in its normal flow, 
from the left auricle into the ventricle, and, when the ventricle is 
filled, that the cardiac muscle contracts on all sides equally. Nor- 
mally, the mitral valves close the auriculo-ventricular opening and 
prevent any of the blood from regurgitating into the auricle, and 
the greater the pressure the tighter they become. Abnormally the 
blood is still pressed upon on all sides as before, and, trying to escape, 
as do all liquids, from pressure, finds that, owing to disease of these 
valves, it can in part at least, slip back into the auricle from which 
it came, rather than pass out into the high pressure of the arterial 
system. The ventricle, therefore, propels blood in two directions— 
in the wrong way and in the right way. If the leak is large enough 
to permit of the regurgitation of a large part of the blood, then 
death occurs. Digitalis does good in mitral regurgitation because, 
by increasing the force of the ventricle, it increases the friction at 
both the mitral leak and the aortic opening; but, as the aortic open- 
ing is a large one and the mitral leak a small one, the greater quantity 
of blood passes out into the circulation. It also does good because 
it strengthens the heart muscle and contracts the muscular ring 



HEART DISEASE 813 

which surrounds the auriculo-ventricular orifice, therefore rendering 
it easier for the valves to close the mitral opening. The same 
fact arises for consideration as before— namely, that it is not the 
amount of leak, but the amount of supply to take its place, which is 
the vital question in the case. Rarely relief does not occur, and 
the patient is made worse by digitalis, because the leak is increased 
as much as the normal flow. 

Murmurs associated with evidences of cardiac failure do not always 
indicate the presence of valvular disease, for dilatation of the mitral 
orifice may prevent the proper approximation of the valves. In 
such a case digitalis, by overcoming the relaxation, may produce cure 
of an apparent valvular defect. 

In mitral obstruction the difficulty is that the blood cannot enter 
the ventricle with sufficient rapidity, and this part of the heart con- 
tracts before it is well filled. By the prolongation of diastole the 
blood is given sufficient time to enter and the ventricle is filled, 
sending out into the system a large w T ave of blood when it contracts. 
Further than this, the stimulation of the right ventricle by the 
digitalis enables this part of the heart to overcome the tendency to 
congestion which arises from the obstruction in the left side of the 
heart. Often the right side of the heart must be relieved by vene- 
section and active purgation. 

When the obstruction at the mitral orifice is so great that the 
auricle becomes distended and its power impaired so that it cannot 
well propel blood through the auriculo-ventricular opening, it not 
infrequently happens that great arrhythmia develops, not only as 
to the regularity of the heart sounds, but also in respect to the 
amount of blood which is expelled at each ventricular contraction. 
This irregularity is not alone due to stretching and exhaustion of 
the auricular wall, whereby the conductivity of the auriculo-ven- 
tricular fibers, as they pass through the auricular wall, is impaired, 
but to damage of His' bundle by the inflammatory process originally 
present, whereby tissue is destroyed, or the blood supply of the 
bundle is interfered with. Such a lesion in His' bundle may result 
in preventing some impulses from reaching the ventricle and so 
beats are missed. (See Digitalis, Part II.) Digitalis should be 
given with great caution, or not at all, in mitral stenosis with missed 
beats, because by its power of still further decreasing the conductivity 
of His' bundle, it may induce complete heart-block so that the 
auricles and ventricles are completely dissociated. Under these 
circumstances, the use of digitalis had better be avoided, or only 
small doses used, until by rest in bed, purgation, and the use of 
other remedies, such as caffeine, strychnine, or ammonia, the action 
of the heart is improved. Atropine in the dose of T ^ ¥ grain (0.0001) 
four times a day is very useful. (See Figs. 130 and 131.) If there 
is much orthopnea and other evidence of circulatory failure, stro- 
phanthin or strophanthone may be given intravenously, but it is 



814 



DISEASES 



not to be forgotten that after the use of full doses of digitalis this 
use of strophanthus may induce sudden cardiac arrest. Strophan- 
thin is given in the dose of 1 cc of a 1 : 1000 solution, put up in ampules. 
Strophanthone diluted with salt solution may also be given hypo- 
dermically in the dose of 1 cc the contents of 1 ampoule, equal to 



Fig. 130. — Showing partial heart-block. The auricle beats about 100 a minute. 
The ventricle only 50 a minute. Indication is for atropine. Upper tracing jugular 
vein. Lower tracing radial artery. 

about gV grain of strophanthin, as it does not cause the intense 
irritation caused by strophanthin, or intravenously in the dose of 
0.5 cc or half an ampoule (See Strophanthus.) 

There is, however, another condition of the heart, met with most 
frequently with mitral stenosis, called auricular fibrillation, in which 



Fig. 131. — Same patient after taking ¥ V grain of atropine four times a day which 
caused disappearance of heart-block. Auriculo-ventricular rhythm reestablished. 

digitalis may do great good. In this state the auricle does not 
contract at all, but remains dilated, and over its surface fibrillary 
thrills occur. No impulses pass to the ventricle from the sino- 
auricular node by way of His' bundle, and the ventricle acts of 
itself, the auricle being only a dilated bag through which the blood 



HEART DISEASE 



815 



passes. The signs of auricular fibrillation are a disappearance of 
the presystolic murmur and the development of a ventricular pulse 
in the jugular veins, best determined by the use of a sphygmocardio- 
graph or the electrocardiograph. How the digitalis does good is 
not clear, unless by stimulating the right ventricle it drives the 



c y c vc 



Jugular 




Radial 



Fig. 132. — Showing auricular fibrillation with irregular ventricular contraction. 

blood through the left auricle, and by increasing the power of the 
left ventricle improves the systemic circulation. It also tends to 
block some of the shower of impulses which attempt to cross His' 
bundle. Large doses are usually needful in this state, but they 
should not be continued over two or three days as a rule. Their 



Jugulai 



Radial 



Fig. 133.- 



-Shows restoration of normal sinus rhythm and regular ventricular 
contraction induced by full doses of digitalis. 



continuance should be controlled by the use of the sphygnlocardio- 
graph (see Figs. 132 and 133) or the electrocardiograph. 

In aortic stenosis there is obstruction to the normal flow of blood 
out of the heart, and the digitalis is needed to increase the ventricular 
force, so that it may overcome the difficulty. 



816 



DISEASES 



In aortic regurgitation digitalis, by its stimulation of the heart 
may cause a sufficient output of blood to clear itself of the regurgitant 
flow, but in many cases the drug fails because the prolongation of 
diastole gives so much more time for the blood to flow backward 



October 



November 




Fig. 134. — Paroxysmal tachycardia. No benefit from moderate doses of digitalis. 
Large doses cured. Blood-pressure rose as pulse-rate fell. Dotted-line pressure. 



into the dilating ventricle. If the mitral valves are incompetent 
because the left auriculo-ventricular orifice is studded or the valves 
diseased as afcomplication of aortic regurgitation it is indicated. 
The other cardiac remedies to be used in such cases are strophanthus, 



HEART DISEASE 817 

in the form of the tincture, dose 5 to 20 drops (0.3-1.3); adonidin, 
dose I to J grain (0.015-0.3), and sparteine, \ grain (0.3). These 
remedies may also be used in the other forms of cardiac disease 
where digitalis fails. It is important to remember, however, that 
some cases of aortic regurgitation do improve, at least temporarily, 
under digitalis, by reason of the fact that the weary and dilated 
muscle walls of the ventricle have their toxicity restored by this drug. 

Physicians often meet with cases of severe valvular disease in 
which there are present a laboring heart, distended jugulars, and 
cyanosis, indicating engorgement of the right ventricle. This is to 
be relieved by free venesection from the arm, and, after the engorge- 
ment is removed, by the use of a mercurial and a saline purge and 
digitalis. 

If many cases of cardiac disease there are associated with the 
heart lesion general debility and anemia. These cases should be 
treated not only by the use of heart tonics, but also by iron, arsenic, 
simple bitters, and, if constipation is present, by mild purgatives. 
Five drops of Donovan's solution are often very useful. 

In cardiac dropsy digitalis and the other heart stimulants do 
good by raising blood-pressure and pulse force, and in some instances 
by helping the kidneys to increased efforts at elimination. (See 
Dropsy.) In these cases, too, the patient will often be greatly 
benefited if he receive every few days a full dose of blue mass and 
of one of the hydragogue cathartics, which will relieve the dropsy 
and unload the portal circulation. (See Colocynth.) 

On the other hand, if the heart is feeble and the arterial tension 
is high, not only must sodium nitrite be given to relax the spasm, 
but. in addition a cardiac tonic must be employed. As digitalis is 
prolonged in its effect and sodium nitrite is fleeting, the digitalis 
should be given every eight or twelve hours, and the sodium salt 
every three or four hours. 

In cases of threatened ruptured compensation or cardiac fatigue, 
before attempting to lower blood-pressure which is higher than 
normal, the physician must be sure that such a high pressure is not 
essential for the comfort and even the life of the patient, as fibroid, 
tortuous vessels render a high pressure necessary if the circulation 
is to be maintained. In such instances the nitrites do no good and 
often do actual harm. The circulatory strain is best relieved by 
the use of the electric-cabinet bath or any form of hot-air treatment 
with massage, and the use of the iodides may be valuable. 

When compensation is suddenly ruptured and circulatory failure 
is imminent, the use of ether and ammonia is to be resorted to at 
once, and these are to be followed by strophanthin intravenously 
or strophanthone intravenously or hypodermically, or by digitalis 
by the mouth or digitalone hypodermically. Pituitrin may also be 
given intravenously, the contents of an ampoule being used. If 
venous turgescence is present great relief often follows free vene- 
section. (See Venesection.) 
52 



818 DISEASES 

In cardiac palpitation dependent upon indigestion, this condition 
must be relieved by appropriate digestive remedies; but in that 
form of palpitation due to overexertion or heart strain digitalis is 
useful. Iron is to be used if the irritability is due to anemia. Tea, 
coffee, tobacco, and excessive venery are to be forbidden. Sometimes 
nux vomica does good by stimulating the heart and nervous system, 
and belladonna seems of great value where arrhythmia is present. 
In other cases of arrhythmia the patient will be more benefited by 
the use of sparteine, or aconite and digitalis with one of the bromides. 
(See Aconite.) 

In cardiac dilatation and asthenia digitalis is often very useful; 
but should the patient be advanced in years and have a tendency 
to arteriosclerosis, we should, simultaneously, give sodium nitrite 
or iodides to relieve any arterial spasm which resists the action of 
the heart. Very often such patients will suffer from scanty secre- 
tion of urine and albuminuria, and will develop congestion of the 
kidneys. This may be controlled and greatly relieved by the use 
of full doses of digitalis, say 5 to 10 drops of the tincture every 
four hours, with 20 grains of bitartrate or citrate of potassium 
every four hours. The addition of the diuretic very greatly aids 
in the diuretic effect of the digitalis in these cases. Sometimes diu- 
resis can only be established after free purgation. In some cases 
it is wise to substitute for the digitalis either strophanthus or caffeine. 
Both should be given freely, say 3 grains (0.2) of pure caffeine, or 
10 minims (0.65) of the tincture of strophanthus, every four hours. 
(See Nephritis.) 

In cases of myocardial degeneration arising during the course of 
acute infectious fevers, digitalis is of little value. In chronic myo- 
carditis with or without valvular disease it may prove helpful, but 
if it causes irregularity must not be continued. (See Mitral Stenosis.) 
Usually the nitrites should be combined with it in these cases for 
obvious reasons. 

Cardiac hypertrophy is rarely seen without some other lesion 
accompanying it, but it may occur from prolonged and excessive 
exercise or other cause. It is to be treated by absolute rest or 
avoidance of excessive exercise, and by moderate amounts of food 
of a non-stimulating character. Wines and coffee should be for- 
bidden, and a belladonna plaster may be placed over the precordium 
if the action of the heart is very excessive. Both palpitation of the 
heart and cardiac hypertrophy are favorably influenced in many 
cases by aconite or veratrum. 

Physicians who are in the habit of examining young men pro- 
fessionally will constantly have their attention called to a condition 
of shortness of breath on exertion, palpitation, or violent pulsation 
of the heart, and in some instances the development of severe symp- 
toms which, at first glance, may seem to be those of true angina 
pectoris. In many of these youths there will be a history of the 



HEART DISEASE 819 

excessive use of tobacco, or that they have left college, where they 
indulged in severe athletic exercise, such as running or bicycle 
racing, and have entered business, where they lead a most sedentary 
life. In these cases the condition which exists is comparable to that 
which exists in a steamship whose engines are too strong for her 
hull. The heart, which has heretofore been supplying the body of 
an athlete with blood, now finds itself too strong for the sedentary 
individual. There is probably no remedy which will give such 
good results under these circumstances as aconite, in the dose of 1 
minim (0.06) of the nuidextract or 5 to 10 minims (0.3-0.6) of the 
tincture three times a day, particularly if at the same time a good 
belladonna plaster about four inches square is applied over the 
precordium. Many cases of tobacco heart, in which there is ar- 
rhythmia, with an excessive cardiac impulse over the precordium, 
with palpitation on exertion, will be benefited by aconite used in 
this way; but where the heart seems much depressed, so that the 
apex beat is feeble and the first and second sounds are not clearly 
heard, aconite will seldom, if ever, do good. 

In that form of functional cardiac disorder due to indigestion 
aconite is not capable of producing the results which are obtained 
in the cases which have just been mentioned. It may, however, be 
used as a remedy of value at the same time that the physician is 
directing his attention to the cause of the trouble— namely, the 
gastro-intestinal disorder, the treatment of which is foreign to this 
article. Here, again, a condition of cardiac feebleness contraindicates 
the employment of this drug. 

Passing to the employment of aconite in cases of true cardiac 
disease, we find that a careful study of a certain number of cases 
will soon show the physician that this drug is capable of doing more 
good in some instances than is digitalis. 

The history of the following case illustrates this point: A man, 
aged nineteen, was brought to the hospital suffering from aortic 
regurgitation, and as a result of this was attacked with dyspnea on 
the slightest exertion, marked cardiac arrhythmia, with palpitation, 
some giddiness, and a tendency to nose-bleed. He stated that in 
the early part of the year, and for several years preceding it, he 
had been a deck-hand on a coastwise vessel, where he performed 
hard manual labor, notwithstanding the condition of cardiac disease 
which was present, and of which he knew nothing. During this 
time he suffered from no symptoms indicating cardiac disorder. In 
other words, compensatory hypertrophy was complete. Because 
of the exposure incident to his work he was forced, under the advice 
of a physician, to earn his living on shore. He was not successful in 
obtaining employment, and a prolonged period of muscular inac- 
tivity followed. As a consequence the cardiac hypertrophy, which 
had hitherto been compensatory, became excessive, and he suffered 
from marked cardiac palpitation, with a throbbing sensation in 



820 DISEASES 

the extremities, and from a distressing cough. Early in the study 
of the case it was recognized that these disorders were due to the 
excess of cardiac hypertrophy, and not to failure in compensation, 
and, as a consequence, that a cardiac depressant was indicated 
rather than a cardiac stimulant in the shape of digitalis. He was 
given from 1 to 2 minims (0.06-0.12) of the fluidextract of aconite 
three times a day, and during the continuance of this treatment 
was purposely confined to bed. At the end of a week so much 
improvement had taken place in his condition that he was allowed 
to rise and go about the ward as he wished, and after four weeks, 
the medicine being continued during this period, he was so improved 
that he was discharged from the hospital, with no other evidence 
of cardiac disorder that physical examination would show. 

Great care must be taken to differentiate the overaction of the 
heart, when feeble and dilated, from the overaction of excessive 
hypertrophy, the more so as the former is the state more frequently 
met with. If this is not done serious damage may result. An ice- 
bag over the heart is often all that is necessary, in addition to rest, 
to quiet this viscus. 

When aconite is used, rest in bed is essential, in order that the 
heart may not be excited to great activity by exercise of the limbs, 
and also because the recumbent posture permits larger doses of the drug. 

An exceedingly useful treatment of valvular disease with or with- 
out ruptured compensation is rest in bed without medication. The 
results in some cases are often remarkable. 

Fatty heart occurs in two forms: that in which true fatty degen- 
eration has taken place in the muscular fiber, and that in which 
there is a deposit of fat about the heart and between its fibers. 
Nothing of any importance can be done for the first state, except by 
the use of nitroglycerin or by the iodides to relieve arterial tension 
if it be too high. Strophanthus with or without nux vomica may 
be useful to relieve symptoms of cardiac distress. Much can be 
done for the second form. In neither form is digitalis of much value. 
If given, it should be combined with nux vomica, or nux vomica 
may be given alone in full doses. The patient suffering from the 
second form of heart trouble is nearly always obese, and should 
abstain from fats and rich foods, from all sweet wines and malt 
liquors, from sugars and milk, and at the same time take exercise. 
At first this treatment may cause dyspnea, but by gradually increas- 
ing the severity of the exercise much can generally be effected in 
the end, with marked improvement in the cardiac action. (See 
Obesity.) 

Heart disease associated with failure of the muscle may not only 
be treated with drugs, but with other remedial measures, such as 
gentle, active exercise, passive exercise, and baths, the latter being 
given with care to avoid too great shock and for the purpose of 
improving the general circulation. 



HEART DISEASE 821 

The movements are so-called resistance movements, the patient 
slowly flexing and straightening his limbs and neck against gentle 
resistance on the part of an attendant. By this means the circu- 
lation of blood and lymph in the tissues is aided without tiring the 
heart. These resistance exercises do not, however, agree with all 
cases. In persons with very feeble hearts gentle massage is far 
better. The rule should be never to give enough exercise or massage 
to cause acceleration of the respiration or marked increase in the 
action of the heart. Very feeble cases should have the massage at 
the first part of the treatment, the exercise next, and the baths last. 

Before considering the use of the Nauheim bath it is necessary 
to have a clear conception of what it is and the methods by which 
it does good. There are six springs at Nauheim, of which three 
are used for bathing and three for drinking purposes. The latter 
are not of great importance and do not form part of the "cure" in 
the strict sense of the word, although the water from the "Kur" 
and " Karlsbrunnen" springs are sometimes sipped in the morning 
before breakfast for their laxative effect. 

The bathing waters are derived from three sources: No. 12, or 
Friedreich Wilhelms Quelle; No. 7, or Der Grosse Sprudel; and 
a new one, called No. 14. The water of all these is very heavily 
charged with carbonic acid by Nature. So great is the pressure 
that the water is forced upward as high as fifty feet from a vertical 
pipe-nozzle. In the case of springs 7 and 12 the delivery pipe per- 
mits the water to shoot upward, and it then falls back into adjacent 
tanks, so that during its rise and fall a large amount of gas is lost, 
and much of the lime and iron held in solution is precipitated in the 
tanks. This w r ater is led to bath-tubs, and if the patient is feeble 
and the "cure" is just beginning, it is often diluted with plain water 
and sometimes heated. This forms the Thermal Sool-bad. 

Other baths are supplied by pipes which carry the water directly 
from the earth without the gas being allowed to escape in any quan- 
tity. This water sparkles as does soda-water, and is called the 
Sprud el-bad. Still another bath is provided in which there is an 
outflow opening as well as an inflow opening, and in which the patient 
sits in a tub into which freshly charged water is rushing as fast as 
it runs out. This is called the Strom-bad. These baths are all 
therapeutically powerful, but, naturally, the first is not so active 
as the last. 

The therapeutic value of these baths depends upon their ability 
to cause dilatation of the peripheral capillaries, which thereby 
relieves internal congestions and enables the heart to pump blood 
more easily through the capillaries. They also stimulate the heart 
by reflex nervous action. The method of treating cardio-vascular 
disease by the use of carbonated baths and gentle resistant exercises 
achieved its popularity at Nauheim, Germany. These baths have 
been duplicated in this country at a number of sanatoria and health 



822 DISEASES 

resorts, but there is little doubt that the absence from business or 
home cares, combined with change of scene and methods of living, 
is chiefly responsible for the benefit that accrues in many cases. 
In properly selected cases the baths and exercises do good but they 
should be given under the direction of a physician trained in their 
use. The indications for this plan of treatment may be stated as 
follows: Functional cardio- vascular disorders as seen in over- 
worked men and women, in which cases the treatment increases the 
circulatory tone. So, too, cases showing cardio-vascular feebleness 
after one of the acute infectious diseases may be benefited unless 
there is evidence of distinct myocardial feebleness or degeneration 
as shown by the stair-climbing test or dyspnea on very slight exertion. 
Cases of cardiac fatigue due to valvular disease with little or no 
myocardial degeneration and cases of discomfort or pain in or about 
the heart due to the excessive use of tea, coffee, tobacco or alcohol 
are benefited. It will be seen that nearly all these states yield to 
other methods of treatment, as, for example, rest, tonics and small 
doses of ^digitalis. 

The contraindications are fairly definite: Valvular disease with 
rupture of compensation to such extent that there is considerable 
edema and a tendency to the accumulation of fluid in the serous 
cavities, or if the liver is distinctly engorged and tender; cases of 
angina pectoris, well-developed cardiac degeneration, and cases 
manifesting signs of acute inflammation in the myocardium, endo- 
cardium, or pericardium. Soo too in cases of high arterial pressure 
(200 systolic), or cases with high diastolic pressure and still more 
important, as a contraindication, is a high diastolic and a relatively 
low systolic pressure. 

These baths may be prepared artificially and are resorted to in 
this country, being now installed in several watering-places. The 
formulae for making the baths are as follows in each 40 gallons of 
water at 95° F.: 

Bath No. 1 : sodium chloride, 4 pounds; calcium chloride, 6 ounces. 

Bath No. 2 : sodium chloride, 5 pounds; calcium chloride, 8 ounces. 

Bath No. 3: sodium chloride, 6 pounds; calcium chloride, 10 ounces. 
< Bath No. 4: sodium chloride, 7 pounds; calcium chloride, 10 ounces; 
sodium bicarbonate, \ pound; hydrochloric acid (25 per cent.), 12 
ounces. 

Bath No. 5: sodium chloride, 9 pounds; calcium chloride, 11 
ounces; sodium bicarbonate, 1 pound; hydrochloric acid, li pounds. 

Bath No. 6: sodium chloride, 11 pounds; calcium chloride, 12 
ounces; sodium bicarbonate, 2 pounds; hydrochloric acid, 3 pounds. 

The alkali should always be slightly in excess unless a porcelain 
or papier-mache tub is used. 

A small bottle containing the hydrochloric acid is submerged at 
the bottom of the tub, uncorked, and its contents allowed to escape 
into the water, in which effervescence at once occurs, the patient 



HEMORRHAGE 823 

entering the bath at that time. The numbers of the baths simply 
indicate different strengths. Patients may never use them stronger 
than that represented by the second or third formula. Toward the 
close of the treatment the temperature may be lowered to 85° F. 

As with all other methods of treatment, the cases submitted to 
this treatment should be carefully selected, as it has its therapeutic 
limitations. This treatment does not necessarily exclude the use 
of drugs. A liberal vegetable diet, with small amounts of meats, is 
given. 

HEMORRHAGE. 

(Including Menorrhagia, Metrorrhagia, Hemoptysis, Hematemesis, 
Intestinal Hemorrhage, Hematuria, and Post-partum Hemorrhage.) 

Under this heading will be considered all forms of hemorrhage 
which we may endeavor to control by drugs or measures not directly 
surgical in their scope, with the exception of epistaxis, which has 
already been spoken of. 

Whenever a hemorrhage can be arrested by the application of a 
ligature or by compression, as in a cut of the ringer or some similar 
wound, no styptic should be used. Styptics are employed for the 
double , purpose of constringing the tissues and coagulating the 
blood, and, in consequence, form coagula which tend to make a 
septic mass about the wound. In their place the physician should 
resort to a compress soaked in some antiseptic liquid or filled with 
some disinfectant powder, and if this fails to control the bleeding, 
then torsion or ligation of the bleeding vessel becomes necessary. 

Where the bleeding point cannot be reached by direct compression 
or for ligation, the use of packing and of astringents is advisable, and 
torsion or drugs which are antihemorrhagic may be used by the mouth 
if coagulation is delayed. 

In all forms of hemorrhage in which the flow has been sufficiently 
great to endanger the patient's life, resort should be had to hypo- 
dermoclysis, intravenous injection or to transfusion. (See Hypoder- 
moclysis, Intravenous Injections, and Transfusion, Part III.) 

In cases in which there is reason to believe that the hemorrhage 
continues because of diminished coagulability of the blood, par- 
ticularly in hemorrhage in the newborn and in jaundice, a hypodermic 
injection of fresh blood serum from a healthy adult should be resorted 
to, to provide the ferment needful for coagulation. An ounce (30.0) 
repeated every day for several days is usually the amount required. 
(See Hemostatic serum, Part III.) 

Gelatin has been employed externally to control hemorrhage, and 
has been given hypodermically to aid in the coagulation of blood 
in bleeding parts which cannot be reached directly. Lancereaux and 
Paulesco use the following formula: 

1$ — Gelatini, 

Sodii chloridi aa gr. cl (10.0) 

Aqua destillatae Oij (1000 cc) 



824 DISEASES 

This mixture is sterilized by heat and 2 ounces (60 ce) are injected 
into the tissues of the thigh or buttock. 1 This is increased to 5 
ounces (150.0) in later injections if they are needed. Usually one 
or two doses are sufficient. A like solution may be used locally to 
check oozing. It is of little value. 

Menorrhagia is an excessive flow of menstrual blood, either exces- 
sive in quantity during two or three days or continuing an unusual 
number of days; while metrorrhagia is a state in which bleeding 
takes place from the uterus independently of menstruation and at 
any period of the month, or even after the menopause has occurred. 

Menorrhagia is not to be determined by the amount of the flow, 
but by whether the loss is sufficient to cause ill health or to indicate 
disease. In some cases it is a means of relieving plethora. 

When the physician decides that something should be done to 
improve the condition of the patient, when suffering from either 
menorrhagia or metrorrhagia, it is necessary for him to find out 
whether a polypus, fibroid growth, endometritis, carcinoma, or other 
form of uterine disease is directly responsible for the trouble, and in 
the meantime to employ drugs known to act favorably upon uterine 
hemorrhage. The most prominent of these drugs are ergot, cotar- 
nine, and oil of erigeron, the first and second being the best for active 
bleeding, the second and third for oozing and for cases where there 
is a continual "show." Cotarnine hydrochloride is given in pill or 
capsule in the dose of 1 to 4 grains four times a day. The fluidextract 
of ergot may be given in varying dose, from 10 to CO minims (0.6-4.0), 
according to the necessities of the case, and the oil of erigeron in 
capsule in the dose of from 3 to 5 minims (0.2-0.3), or, if capsules 
cannot be had, the physician may employ the oil in an emulsion 
made by using syrup of acacia or other similar substance. Locally, 
sterile cotton wet with a sterile solution of adrenalin chloride (1 : 5000) 
may be employed. 

Where menstruation is irregular and the menorrhagia is almost 
a metrorrhagia, bromide of potassium or sodium in the dose of 10 
grains (0.6) several times a day is often very serviceable. The 
water of hamamelis in the dose of 1 dram (4.0) three times a day 
is sometimes useful. Cannabis, if an active sample is obtainable", is 
also said to be of service, but the writer has never used it to any 
extent. Oil of cinnamon in the dose of J dram (2.0) is said to be 
efficacious in the slow oozing of some cases where erigeron cannot 
be used or obtained. Sometimes, where congestion of the pelvic 
viscera is the cause of the trouble, dry cups over the sacrum give relief. 
Often, however, the case is purely surgical. 

Hemoptysis, or hemorrhage from the lung, is usually due to tuber- 
cular ulceration of a small or large bloodvessel or to mitral disease, 

1 The gelatin should be boiled at least an hour, as tetanus spores are often present 
and are not killed by being exposed to heat for a short time. 



HEMORRHAGE 825 

and the life of the patient depends more upon the rapidity with 
which a clot naturally forms than upon the skill of the physician. 

Hemorrhage from the lung must be regarded as any other hemor- 
rhage. The object of the physician is not to stimulate the heart 
and vasomotor system, thereby increasing the leakage from the 
bleeding vessel, but to lower the arterial pressure to as low a point 
as is safe. With this end in view nitroglycerin may be given hypo- 
dermically in the dose of tto to 5V of a grain (0.0006-0.0014) or 5 
minims of amyl nitrite may be inhaled. If these drugs are not 
obtainable, chloroform may be given by inhalation with care, to 
lower blood-pressure and quiet the overacting heart. (See Amyl 
Nitrite.) 

The rule to follow is best stated as follows, if the hemorrhage has 
been severe and the patient is feeble: Place the head lower than 
the feet and apply Esmarch bandages to the limbs to keep the blood 
in the vital parts as much as possible. The use of stimulants can 
only increase the hemorrhage by increasing the pumping power of 
*the heart and by dislodging the clot from the eroded bloodvessel. 

Daremburg and Yeo have employed ice or ice-cold compresses to 
the scrotum or vulva in cases of hemoptysis, and claim good results 
from this use of cold. Cold must not be used if the patient is very 
feeble. 

To allay nervous excitement many writers advise that a hypodermic 
injection of morphine should be used. Chloral and the bromides 
are often better remedies for this purpose, and should be given by the 
mouth, or, if vomiting is present, they should be given by the rectum, 
dissolved in starch-water. (See Chloral and Bromides.) 

Sometimes the patient can point directly to the spot where he 
thinks the hemorrhage exists, and under these circumstances a dry 
cup or a piece of ice placed over this point may perhaps prove useful 
by causing a reflex contraction of the deeper bloodvessels. 

Though text-books order atomized solutions to be inhaled and 
other remedies to be taken by way of the lung, in most cases these 
measures will be found impracticable, because the nervousness of 
the patient and the constant cough will not permit of inhalations 
to any extent, and even if a full breath can be taken, it generally 
increases the bleeding and coughing. 

In cases where severe or repeated hemoptysis develops it may be 
unnecessary to resort to artificial pneumothorax. (See Tuberculosis.) 

After an attack of hemoptysis there is great danger in many 
cases of a traumatic pneumonia being set up by the presence of the 
extra vasated blood. This should be combated by the use of a 
carefully regulated diet, and the reduction of any arterial excitement 
by small doses of aconite in persons not weakened by advanced disease 
or by the bleeding. Complete rest in bed is to be insisted on, and no 
stimulants allowed in food or drink unless the weakness of the 
patient requires them. 



826 DISEASES 

Hematemesis.— This depends either upon some injury to the 
stomach, or, much more commonly, upon gastric ulcer, cancer, or 
cirrhosis of the liver, and is one of the easier of the so-called "internal 
hemorrhages" to treat, because by ordering the patient to swallow 
styptic drugs we can act directly upon the bleeding surface. 1 Adre- 
nalin in the dose of a dram (4.0) of 1 : 1000 solution may be given. 
Morphine may be used hypodermically to produce general and 
gastric rest and to aid the formation of a clot. Bandages to the 
extremities and external heat should be applied if the hemorrhage 
is sufficiently great to cause faintness. (See Gastric Ulcer.) 

Hemorrhage from the bowel is to be treated according to its point 
of origin. If in the small intestine, as in duodenal ulcer, the medi- 
cines must be used by the mouth; if it be from the colon or rectum 
or from hemorrhoids, treatment must be by way of the anus. In 
any case rest in bed is essential, and as soon as the patient recovers 
from the hemorrhage relief from the duodenal ulcer by surgical 
measures should be resorted to. 

Hemorrhage from the bowel is best combated by the hypodermic 
use of morphine, and a small ice-bag to the belly if the patient is 
not in collapse. As a matter of fact no remedy given by the mouth 
has any direct effect in intestinal bleeding. 

In melena neonatorum or in the bleedings of hemophilia, the injec- 
tion of human serum, horse serum, hemostatic serum, or transfusion 
are to be utilized. (See Transfusion.) 

Where the hemorrhage is dependent upon ulceration of the colon, 
rectum injections are to be resorted to. These are both styptic 
and curative, the styptic injections being particularly useful when 
the bleeding is to be stopped at once, the others where it is sought 
to remove the condition producing the trouble. 

To the first class belong alum, sulphate of copper, Monsel's solu- 
tion, sulphate of iron, tannic acid, and cold water. In the second, 
we find nitrate of silver, the sulphates of copper and iron, and the 
chlorate of potassium. 

The alum solution used should be fairly strong, 10 grains to the 
ounce (0.6-30.0); the copper, 5 grains to the ounce (0.3-30.0); the 
Monsel salt, 10 grains to the ounce (0.6-30.0); or J to 1 dram of 
Monsel's solution to each 2 ounces (2.0-4.0:60.0) of water. The 
tannic acid should be used in the strength of 20 grains to the ounce 
(1.3-30.0) of water and glycerin. When chlorate of potassium is 
used, it should be employed in saturated solution in small injections 
(25 grains to the ounce [1.6-30.0]), or in weaker solution if the injec- 
tion be a large one (10 grains to the ounce [0.6-30.0]). Another 
useful drug, if the site of the hemorrhage can be reached, is adrenalin 

1 Hematemesis also ensues as a result of swallowing blood which has escaped into 
the mouth or nasopharynx, and this symptom is sometimes induced by malingerers in 
order to further their ends. These forms of hematemesis should, of course, be sepa- 
rated from those dependent upon some lesion in the stomach itself. 



HEMORRHAGE 827 

chloride in the proportion of 2 drams of the ordinary 1 : 1000 solution 
in a half -pint of normal saline solution. 

These injections should be carefully given, and the success or 
failure attending the treatment of these states depends as much 
upon the technique of the operation as upon the particular medicinal 
substance employed. It should never be forgotten that an injec- 
tion designed for local medication should be as small in bulk as 
circumstances will permit. Thus, in inflammation of the rectum 
the amount of the injected liquid should not be above 4 ounces 
(120.0) at the utmost, and preferably 2 ounces (60.0) unless the 
diseased area is high up. An enema is given in bulk so as to cause 
distention and excite the bowel to movement, whereas from a medi- 
cinal injection no movement is desired. (See Enteroclysis, Part 

Hematuria is a condition in which blood appears in the urine, 
and may be divided into two classes: that in which the blood 
comes from the kidney or bladder, and that in which it comes 
from the urethra. In the first class the blood is always well mixed 
with the urine, which is changed in color from its decomposition, 
and the blood is present either during the entire act of urination or 
just at the end of the act. In those instances in which the blood 
is in the first part of the stream it arises in the urethra, is nearly 
pure, and not well mixed with the urine. 

If the hemorrhage is alarming, injections of adrenalin chloride 
(1:5000) may be used; or astringent washes, such as 2 or 3 grains of 
alum to the ounce of w T ater, may be injected into the bladder. It 
must be remembered, however, that alum fills the bladder with clots, 
which are not readily passed and are liable to become septic. 

Malarial infection is sometimes accompanied by hematuria or 
hemoglobinuria. The cause is obscure, and an immense amount of 
discussion has taken place as to its proper treatment. Many physi- 
cians assert that the use of quinine in these cases produces disastrous 
results; others claim that the drug is most valuable. The value of 
quinine consists, undoubtedly, in its ability to prevent other attacks, 
rather than to relieve that already present or its result— the hema- 
turia. If an examination of the blood shows the presence of the 
estivo-autumnal parasite, quinine is to be freely used; but if not, it 
is to be avoided. Personally the author believes that malarial 
hematuria and hemoglobinuria will ultimately be found to depend 
upon very different causes. In some cases it will be found that the 
malarial parasite is the cause of the disease. In other instances it 
will probably be discovered that an entirely different organism 
belonging to the same general type of the parasites is responsible 
for the development of this dangerous and much dreaded complica- 
tion. (See Cinchona, Part II.) Sodium thiosulphate is a most 
useful remedy in malarial hematuria in the dose of 5 to 15 grains 
(0.3-1.0) every five hours. Many practitioners use as much as a 
dram of thiosulphate of sodium every two hours until purgation 



828 DISEASES 

takes place, give morphine and atropine hypodermically to relieve 
pain and quiet the stomach, apply cups over the kidneys, and give 
large amounts of water so as to freely flush the kidneys. 

Post-partum hemorrhage is to be controlled by the use of abdominal 
friction and kneading or grasping the dilated uterus through the 
relaxed abdominal wall; by the use of dram doses of the fluidextract 
of ergot or a wineglassful of the wine of ergot, or by the hypodermic 
use of 15 minims (1.0) of pituitrin or of "Ergot Aseptic;" and by 
irritation of the uterine wall by passing the hand, which must be 
absolutely aseptic, up through the vagina into the uterine cavity. 
In other cases vaginal irrigation with sterile water as hot as can be 
borne may be resorted to. 

In all forms of local hemorrhage from small vessels adrenalin 
chloride is to be thought of as a local application, or horse serum 
or coagulose given hypodermically or applied locally. 

HEMORRHOIDS. 

Hemorrhoids are vascular dilatations of capillaries, arteries, or 
venules situated outside or inside of the sphincter ani, or are com- 
posed, in the case of what are called external piles, of tags of skin 
which are more or less vascular and become troublesome when 
inflamed. 

The internal pile if large, is apt to prolapse and to become strang- 
ulated by the sphincter muscle. It is covered with mucous mem- 
brane, and is sometimes very small or like a mulberry in shape, 
consisting of a tuft of capillaries, a loop of an arteriole, or of a venule. 
The capillary or arterial hemorrhoid is apt to be bright red, and to 
bleed profusely when touched or when scraped by hard feces. The 
venous tuft also bleeds, but not so freely, and the blood is not so 
bright in color. In cases in which the hemorrhoids "come down"— 
—that is, pass out through the anus, so being in danger of becoming 
strangulated— the protruding mass should be washed with cold 
water thereby at once cleansing it and reducing its congestion, and 
then gently pushed back with the fingers, which should be well oiled. 
In some cases it is advantageous to push gently into the rectum a 
cold rectal speculum, which will not only replace the piles, but also 
contract their walls and displace the blood with which they are filled. 
Care should be taken that an external hemorrhoid is not mistaken 
for an internal pile, since if an external growth is pushed through 
the sphincter it also becomes strangulated. 

The treatment of internal hemorrhoids is to a great extent identi- 
cal with that of the external variety. A suppository may be used, 
made up as follows, if there is a tendency to slight hemorrhage: 

^ — Acidi gallici gr. xx (1.3) 

Extracti opii gr. j (0.06) 

Extracti belladonna? foliorum gr. ij (0.12) 

Olei theobromatis q. s. — M. 

Fiant suppositorise, No. x. 

S. — Use one every night. 



HEMORRHOIDS 829 

In place of this, distilled witch-hazel extract may be injected into 
the rectum in the quantity of 1 to 2 ounces (30.0-60.0). 

If the hemorrhage is profuse, the physician should use a speculum, 
find the bleeding point, and touch it with strong nitric acid, followed 
by the suppository named above. If this is done, the bowels should 
be confined for some days until the spot under the slough made by 
the acid can heal. 

If the prolapsed hemorrhoid is inflamed and difficult of reduction 
the following ointment of Mathews may be ordered: 

1$ — Cocainse gr. xij (0.8) 

Iodoformi 5j (4.0) 

Extracti opii gr. xxx (2.0) 

Petrolati 3J (30.0).— M. 

S. — Use as a salve. 
Note that this prescription calls for cocaine, not cocaine hydrochloride. The 
reason for this is that the salt of cocaine does not act well when mixed in an ointment. 

If the pile still refuses to be reduced, place the patient in bed and 
apply a hot compress wet with adrenalin chloride solution (1:2000). 
If this fails, operation is demanded. The pile should be incised and 
the clot turned out. 

The treatment of external piles themselves consists in the main- 
tenance of the most rigid cleanliness Immediately after each 
movement the parts should be thoroughly washed by means of a 
sponge dipped in cold water, or, better still, by the use of the bidet 
or a nozzle attached to a fountain syringe or to the general water- 
supply. (See Cold, Part III.) After they are thoroughly cleansed, 
it is well to bathe them with distilled extract of hamamelis. Often 
it is advisable to precede the regular daily evacuation by a rectal 
injection of cold water to soften the feces, and, more important still, 
to decrease congestion. If the inflammation of the external piles 
is very acute, the patient should be placed in bed and the cold injec- 
tions frequently repeated or hot compresses applied to the anus. 
After this a lotion of lead- water and laudanum— laudanum fgss 
(15.0) to dilute lead-water fgij (60.0) may be used. 

If in association with the presence of hemorrhoids there is much 
itching the following salve may be applied: 

]$ — Mentholis gr. xx 

Hydrargyri chloridi mitis gr. xxx 

Petrolati gj (30).— M. 

S. — Apply locally. 

The injection of phenol into hemorrhoids is a dangerous practice, 
and, if employed, only 1 drop is to be used. 

In addition to these applications there are important general rules 
to be observed. 

The patient's habits should be so arranged that the daily act of 
defecation is at night before going to bed, rather than in the morn- 
ing, as under these circumstances the rest in bed relieves congestion 
and soreness, which the maintenance of the erect posture might 



830 DISEASES 

aggravate. Plethoric individuals should not use upholstered chairs, 
as the heat of the body relaxes the rectal tissues. A cane-seated 
chair is best, or an air-cushion with a hollow center. The liver plays 
a most important part in relation to hemorrhoids, and, if it is con- 
gested, congestion of the hemorrhoidal veins is very apt to ensue. 
The connection between the liver and the hemorrhoidal plexus is 
most intimate, since this plexus is formed by the superior hemor- 
rhoidal veins, which are branches of the inferior mesenteric, and 
the middle and inferior hemorrhoidal veins, which terminate in the 
internal iliac. The portal venous system is composed in part of the 
inferior mesenteric vein, and any obstruction to venous flow in the 
liver at once results in engorgement of the hemorrhoidal plexus. 

(For the surgical treatment of piles reference must be made to 
surgical works.) 

HEPATITIS. 

(Acute and Chronic Hepatitis and Hepatic Abscess.) 

Inflammation of the liver may be produced b}^ many causes, such 
as injuries, cold, exposure to high temperatures (as in the tropics), 
syphilis, and the presence of any infectious disease or of parasites. 
It may also arise from alcoholism. The hepatitis of hot climates is 
generally subacute or chronic. The pain, swelling, and general 
symptoms of the acute form of inflammation of the liver are described 
thoroughly in the text-books on the practice of medicine. The 
measures commonly adopted for the relief of the symptoms and 
and the disease itself are of two kinds: the first, medicinal; the 
second, dietetic. 

The patient, if the attack be acute or severe, will commonly be 
found in bed, owing to the pain and fever, but if not he must be 
placed in bed and kept in a recumbent posture. Over the surface 
of the right hypochondrium may be placed a number of small can- 
tharidal blisters; or, if this is not possible, a large mustard plaster 
is to be used. Sometimes hot cloths applied over this area are 
equally efficient. At the same time, if the bowels are confined, a 
saline purgative, such as magnesium sulphate, should be given, and 
it is often wise to precede it several hours by small doses of calomel 
given in fractional doses. The kidneys must be kept active by 
spirit of nitrous ether and citrate of potassium, or by any one of the 
diuretic waters, such as Vichy, in moderate quantities. 

If a single hepatic abscess develops, 1 the best thing to be done is 
to expose the liver and drain it. Very frequently the inflamed 
organ will have fo±med a strong attachment with the peritoneal 
coat of the abdominal cavity. Any constitutional evidence of the 

1 It is well to recall that many cases of hepatic abscess are now known to be due to 
dysentery, and that the diseased state of the lower bowel may result in infection of the 
liver. 



HICCOUGH 831 

presence of pus, as by night-sweats, hectic, or rigors, is a sign for 
immediate interference with the purulent collection. If amebic 
dysentery exists, it must be cured as rapidly as possible by the 
measures generally employed for this purpose, but if this disease 
be the cause of the abscess, the proper treatment is to aspirate the 
pus and inject the abscess cavity with a solution of quinine hydro- 
chloride containing 30 or 40 grains (2.0-2.6). (See Ipecac and 
Dysentery.) Multiple hepatic abscess is beyond our measures of 
relief. 

The diet during the early and later stages of acute hepatitis 
should be limited to those articles of food which are easily digested 
and assimilated, and rich or greasy dishes are to be excluded. 
"Strong foods," as meats of all kinds, particularly beef, pork, and 
mutton, are to be sedulously avoided. All spices in the food must 
be forbidden, and alcohol utterly tabooed. If koumyss cannot be 
had, the patient may be fed on peptonized milk or pancreatized 
oysters. (See Part III.) After an abscess develops the same recom- 
mendations are to be followed, and the diet is to be as supportive as 
possible, small doses of quinine and iron being used. 

In the treatment of the subacute or chronic hepatitis of hot 
climates no remedy compares to freshly prepared strong nitromuri- 
atic acid, used both externally and internally. The acid should be 
a deep lemon color, and be mixed with water only when about to be 
taken in the dose of 3 to 5 minims (0.2-0.25) three times a day. 
This remedy is contraindicated in acute hepatitis, because it acts 
by stimulating the organ, and would only increase the severity of 
the acute form of the disease if administered at this time. Extern- 
ally, it is to be used by mixing it with water and applying it by 
means of a flannel wrung out in the mixture, or by placing it on 
spongiopiline in the proportion of from 1 to 3 nuidrams to the pint 
(4.0-12.0:480 cc) of hot water and applying it over the liver. 
If 3 fluidrams (12.0) irritate the skin too greatly, the smaller quan- 
tity should be employed. This application causes a tingling of the 
skin and a localized sweat. 

The hepatitis due to syphilis generally shows itself as a cirrhosis, 
and is to be treated by antisyphilitic measures. (See Syphilis.) 

If ascites develops from cirrhosis, the liquid is to be withdrawn, 
and frequent aspirations, as often as the liquid returns, have been 
known to result in apparent cure or arrest of the disease. In all 
forms of chronic hepatitis iodide of potassium is a useful remedy in 
the dose of from 5 to 20 grains (0.3-1.3) three times a day, and larger 
amounts should be used if the condition be due to syphilis. 

HICCOUGH. 

Hiccough is an affection arising from many causes, depending 
upon irritability of the nerves supplying the diaphragm as a result 



832 DISEASES 

of gastric irritation, nervousness, uremia, and as a complication of 
several exhausting diseases, such, for example, as typhoid fever. 

The mechanism of its production rests upon the sudden contrac- 
tion or descent of the diaphragm, whereby a vacuum is formed in 
the chest into which the outside air attempts to rush, but is pre- 
vented from doing so by a sudden closure of the glottis, the peculiar 
sound of the hiccough being thus developed. Generally the symp- 
tom stops of itself, but it may become continuous and excessive. 

The remedies to be employed are used according to the cause of 
the disorder. If there be gastric or intestinal irritation, the irri- 
tating matter must be removed by emetics or purges, and nervous 
and local sedatives used. A dram (4.0) of spirit of chloroform does 
good in many cases, and tincture of capsicum may be employed in 
other instances, say 5 to 10 minims (0.3-0.6) well diluted. Spirit of 
camphor, or the tincture of valerian, in the dose of 1 dram (4.0), 
may be serviceable, and Hoffmann's anodyne is peculiarly effica- 
cious in the dose of 1 dram (4.0) in ice-water. In the hiccough of 
typhoid fever nothing compares to musk, 20 grains (1.3) by the 
rectum, and, if this cannot be used, oil of amber may be given by 
the mouth in the dose of 5 to 10 minims (0.3-0.6) in capsule or 
emulsion, and followed by a drink of milk to prevent irritation of 
the stomach. Nitrite of amyl may also be inhaled. When hiccough 
is so persistent as to endanger life it must be controlled by the use 
of bromide of sodium and tincture of deodorized opium given by the 
bowel. (See article on Vomiting for directions; also see Chloretone.) 

Where external remedies are resorted to, ether thrown in a fine 
spray on the epigastrium may check an attack. 

In cases where the affection comes on after meals and is due to 
indigestion, a course of tonic treatment will often give relief. Thus 
nux vomica in pill or tincture, accompanied by some dilute mineral 
acid, such as hydrochloric or nitric, may be employed, or, if the 
stomach is acid- 
ic — Sodii bicarbonatis . . . 5J (4.0) 

Tincturse nucis vomicae f 3J (4.0) 

Tincturae cardamomi q. s. ad f giij (90.0). — M. 

S. — Teaspoonful (4.0) before each meal. 

If the symptoms are due to uremia, a hot pack may be found of 
service, unless contraindicated by advanced depression and systemic 
weakness. Even in the presence of these symptoms it may be 
advisable to resort to this measure, protecting the patient against 
depression by a hypodermic injection of strychnine. 

INCONTINENCE OF URINE. 

Incontinence of urine may be classified either according to its 
forms or the methods of its treatment. 

Four varieties may be recognized as occurring separately, although 



INCONTINENCE OF URINE 833 

all of them may occur in one case. There are cases where the blad- 
der fails to hold the urine day or night, those in which the inconti- 
nence is only nocturnal, and those in which it occurs only upon 
some nervous start or in which the sphincter becomes relaxed from 
general atony. The first of these occurs in children, the last in 
adult females. A fourth form of incontinence depends upon paraly- 
sis arising from centric nervous disorder or from paralysis due to 
retention and consequent paralytic distention. 

Taking up the consideration of the first forms— namely, those 
occurring in children, in which the trouble is generally nocturnal— 
the complete history and the present condition of the case must be 
discovered. Many of the most obstinate cases will yield when the 
urine is made constantly clear and mild by the use of alkalies, and 
others will recover upon the removal of worms from the vagina, 
which have crawled there from the rectum, or upon circumcision of 
a redundant prepuce, particularly if this be tight and smegma and 
urine be found back of it in large or small quantity. The cause of 
the incontinence in both these conditions is reflex irritation of the 
bladder- walls, by irritation at the end of the penis or in the vagina, 
and the reason that alkalies do good is that they render the urine, 
when concentrated and irritating, dilute, alkaline, and mild. Bella- 
donna in these cases is rarely, if ever, curative, and is at most only 
palliative, the condition returning as soon as the passing off of the 
effects of the drug permits the irritation to be felt by the nerves of 
the bladder. After alkaline diuretics have been used belladonna is, 
however, very valuable Where the urine is acid, concentrated, 
and dark in color the following prescription is always useful: 

^ — Potassii citratis 3ij (8.0) 

Spiritus setheris nitrosi f3iij (8.0) 

Aquse destillatse q. s. ad fgiij (90.0). — M. 

S. — Dessertspoonful (8.0) every four hours in a tablespoonful (15.0) of water. 

As the urine becomes clear after several days a few drops of tincture 
of belladonna may be added to the mixture; but if a moderate amount 
is not sufficient, it must not be increased, as belladonna will not cure 
the condition, and may make the urine concentrated— a condition 
directly opposed to that which is wanted. 

In other instances— and these are by no means rare— the urine is 
concentrated and ammoniacal in odor. Under these circumstances 
one of three drugs may be used with advantage, namely hexamethyl- 
enamine (urotropin or uritone) in the dose of 4 grains (0.25) in half 
a glass of water three times a day; or benzoate of ammonium, given 
in the same quantity in capsule after meals. Both of these drugs 
acidify the urine and render it antiseptic, and for obvious reasons 
are harmful if the urine is already acid. 

Sometimes these cases are dependent not so much upon vesical 
irritability as upon weakness of the spinal centers governing the 
bladder. If this be the case, the urine should first be rendered 
53 



834 DISEASES 

mild, and then remedies should be directed to the improvement of 
these parts. The following pill or the succeeding solution should 
be administered: 

1$ — Arseni trioxidi gr. | (0.02) 

Extracti nucis vomicae gr. ij (0.12). — M. 

Fiant pilulae, No. xx. 
S. — One three times daily after meals for a child of eight or ten years. 

Or, 

1$ — Liquoris potassii arsenitis ttlxxiv (1.5) 

Tincturae nucis vomicae lUxxiv (1.5) 

Aquae destillatae q. s. ad f§iij (90.0). — M. 

S. — Teaspoonful (4.0) three times daily after meals for a child of eight or ten years. 

This mixture is so bitter as to be disagreeable, and Fowler's solution 
may often be used alone in the dose of \ to 1 minim (0.03-0.06), 
and at the same time strychnine in gelatin- or sugar-coated pill or 
granule may be given. 

It must be remembered that this last treatment is only to be 
employed in chronic cases devoid of all irritation and dependent 
upon atony. It will not do good if the urine is not previously made 
clear. 

Nothing can be more unfortunate in the treatment of these cases 
than punishment by severe scolding or whipping the child, as it 
never does good, and, the fault being beyond the child's control, 
the unjust punishment makes him sullen, or through nervousness, 
augmented by such treatment, his trouble becomes worse. In some 
cases it may be necessary, in order to cure the habit, to let the child 
drink diuretic waters for years. The patient should always be 
taken from bed when the parents retire for the night and made to 
evacuate the bladder. 

For the incontinence of adult females or males due to atony of 
the vesical sphincter, and which occurs on laughing or sudden move- 
ment, nothing compares, from a curative point of view, to drop 
doses of tincture of cantharides three or four times a day, the urine 
being kept flowing freely from the kidneys by means of alkaline 
diuretics. Attention to the reaction of the urine in these cases is 
also of value. If it is acid, alkalies must be given; and if alkaline, 
uro tropin or uritone is indicated. 

The treatment of the fourth form of incontinence of urine comes 
into the province of surgery. The bladder must be relieved by 
the catheter if the trouble be from retention with distention. If the 
disorder is due to paralysis, nothing can be done except to carry 
out those general measures valuable in such cases— to maintain the 
urine in as normal a state as possible by urinary antiseptics, to 
catheterize frequently with an aseptic catheter, and to wash out the 
bladder every few days or hours, as the case may be, with some 
weak antiseptic fluid, such as the 1 : 10,000 solution of bichloride of 
mercury, or 1 : 200 of phenol, or 1 : 100 of boric acid . 



INDIGESTION 835 

INDIGESTION (GASTRIC AND INTESTINAL). 

Under the heading " Biliousness" the writer has described many 
of the conditions arising out of indigestion, and, this being the case, 
the consideration of that state known as dyspepsia or indigestion 
will only receive attention at this point in so far as its cure is con- 
cerned, without the relief of the symptoms produced. 

Lack of gastric digestion depends for its existence upon a great 
number of causes, and is always a symptom, not a disease. It 
occurs during the course of short or prolonged fevers from atony of 
the gastric walls and glands, from lack of secretion of the proper 
character, from hypersecretion of mucus by the mucous glands, or 
as the result of any one or all of these conditions, and lastly, because 
the food is unsuitable to the case, or is of a kind difficult of assimi- 
lation. Sometimes it is due to organic changes in the abdominal 
viscera, as carcinoma or ulcer, and sometimes to acute or chronic 
gastritis. In each of these states the treatment is, of course, differ- 
ent, because widely separated causative factors must be relieved. 

The indigestion attendant upon the course of fevers can nearly 
always be avoided by a proper diet and the use of predigested food, 
such as pancreatized gruels, milk, or broths. The necessity of 
this artificial digestion is the more readily recognized when we 
recall the investigations of Hoppe-Seyler upon the quality of the 
gastric juice of a patient suffering from typhoid fever, for he found 
that no hydrochloric acid was present. Uffelmann has also found 
in a similar study that the peptone-forming secretion of the stomach 
ceases entirely during fever. 

Where indigestion results from the presence of gastric catarrh 
the remedies applicable to such a state must be resorted to. (See 
Gastric Catarrh.) 

The studies made within recent years upon the chemical condi- 
tions of the gastric contents have changed the methods of treat- 
ment from being empirical to being rational, for it is now known 
that disorders of digestion depend on deficient or excessive acidity 
of the gastric juice, deficient formation of pepsin, stenosis of the 
pylorus, deficient motility of the gastric walls, gastroptosis and 
enteroptosis, and other less important causes. Before carrying 
out any line of treatment the physician must, therefore decide, if 
possible, as to the underlying cause of the dyspepsia present in each 
case, and his decision may be based on well-described subjective 
symptoms by the patient, or upon this description aided, or it may 
be replaced, by examination of the stomach-contents after a "test- 
meal" by the fractional method or the results of axray examination. 

If enteroptosis is revealed by these means or if it is shown to be 
present by the physician standing behind the patient and lifting the 
abdominal contents to their normal level mechanical treatment is 
the first factor in the case. This usually consists in applying 2-inch 



836 DISEASES 

zinc oxide adhesive strips from the middle line, beginning as low 
as the pubis, and running them up obliquely to the level of the 
kidneys or lower ribs as they leave the spine. Each strip should 
overlap the other and the anterior ends of the strips should overlap 
in front. If these prove successful the patient should wear perma- 
nently a light well-fitting belt several inches wide to hold the 
abdominal organs at the normal level. 

In those cases in which the dyspeptic symptoms result from 
imperfect mastication and insalivation of food it is evident that 
careful rules about eating are to be given the patient, with the 
additional advice, which is equally good in all cases, that exact 
meal-hours should be adhered to, since irregularity in meal-hours 
results in imperfect digestion as commonly as irregularity of habit 
in regard to defecation results in constipation. If the dyspeptic 
symptoms are due to deficient secretion of gastric juice, particularly 
if it is found that hydrochloric acid is the chief deficient element, 
one or two plans presents itself for employment. In many cases it 
will be found that the administration of small doses of bicarbonate 
of sodium, 5 to 10 grains (0.3-0.6), before each meal will cause a 
free secretion of gastric juice, particularly if it be given simultane- 
ously with bitter substances which act as stimulants to the gastric 
mucosa. These facts are not based solely on the apparent improve- 
ment in the patient, but also upon careful chemical studies of the 
acidity of the gastric juice by means of the stomach-tube. In mild 
cases the taking of a glass of imported Vichy water (Celestins) 
before each meal serves to provide sufficient sodium to produce 
good effects. 

The bitter substances which it is best to employ in cases of defi- 
cient acidity of the gastric juice are among the simple bitters, such 
drugs as quassia, cascarilla, calumba, and gentian. Among the 
peculiar bitters we have nux vomica, quinine, rhubarb, and con- 
durango. These may be employed in the following form: 

1$ — Sodii bicarbonatis 5J (4.0) 

Tincturse nucis vomicae f 3j vel f 3ij (4.0 vel 8.0) 

Tincturae gentianae compositae . q. s. ad fgiij (90.0). — M. 

S. — Teaspoonful to a dessertspoonful (4.0-8.0) before meals. 

When there is deficient gastric secretion through atrophy of the 
gastric tubules or carcinoma of the stomach, the use of hydrochloric 
acid is the better plan. Under these circumstances the following 
prescription may be ordered: 

3 — Acidi hydrochlorici diluti f3j vel f3iv (4.0-15.0) 

Fluidextracti condurango fgj (30.0) 

Tincturae cardamomi compositae q. s. ad f Biij (90.0). — M. 

S. — Dessertspoonful (8.0) with or after each meal in water. 

The symptoms manifested by persons needing the treatment just 
named are variable, but generally of sufficient constancy in type to 
be fairly pathognomonic. There are generally loss of appetite, some 



INDIGESTION 837 

impairment in general health and nutrition, and marked difficulty 
in digesting food, particularly if it be in solid form. Complaint is 
usually made of a sensation of weight after eating, without any real 
pain, but indigestion is not complete, owing to the food being finally 
disposed of in the duodenum. Often because of the delay in gastric 
digestion there is some belching of gas due to fermentation of the 
food in the presence of warmth and moisture, and without the 
antiseptic influence of the gastric juice. If any food is brought up 
with the belching, it is unaltered or changed only by fermentation. 
Examination of the stomach-contents for hydrochloric acid by the 
phloroglucin-vanillin test will speedily confirm the diagnosis of 
absence of hydrochloric acid, and this confirmation should be sought 
for in every case. The use of hydrochloric acid is also of service, 
in that its presence in a free state causes the pylorus to open and 
permit the food to pass into the duodenum. When it enters the 
duodenum it indirectly aids digestion by causing the secretion into 
the blood of secretin, which in turn causes a secretion of pancreatic 
juice. 

In the cases of gastric indigestion depending upon hypersecretion 
of the acid of the juice a line of treatment quite at variance with 
that just discussed must be instituted. This may be divided into 
the direct and indirect forms, including the remedies which distinctly 
decrease gastric secretion and those which antagonize or overcome 
its acidity after it is poured out from the glands. In the first class 
we find both general and local nervous and glandular sedatives, and 
in the second alkaline drugs. Of the first class we have hyoscya- 
mus, belladonna, and opium from the vegetable kingdom, and the 
bromides, bismuth, and nitrate of silver from the mineral. Of the 
second class we have massive doses of sodium bicarbonate taken 
during or after meals, ammonia, generally in the form of the aromatic 
spirit, and magnesia and chalk. 

As many, if not all, of the cases suffering from hyperacidity are 
of a nervous temperament, these drugs do good by quieting reflex 
activity throughout the nervous system connected with digestion, 
and by a local action on peripheral nerves, or on the glands them- 
selves, diminish secretion. Of particular value for this purpose is 
hyoscyamus, which very markedly decreases gastric secretion, 
directly and indirectly, and at the same time relieves gastric pain 
by its local sedative influence. The bromides in moderate doses 
are also useful. 

Taking gastric ulcer as a typical instance of a condition of exces- 
sive secretion of hydrochloric acid, it will be found that the following 
pill, combined with an absolute milk diet or, for the first few days, 
allowing only rectal alimentation by peptonized food, will be most 
useful : 

1$ — Argenti nitratis . gr. v (0.3) 

Extracti hyoscyami gr. x (0.6). — M. 

Fiant pilulse, No. xx. 

S. — One pill one hour before taking food. 



838 DISEASES 

Sometimes in place of this pill it is wise, particularly if no ulcer 
exists, to give 10 to 20 grains (0.6-1.3) of bromide of strontium one 
hour before meals, and in any case where this fails to control exces- 
sive secretion of acid full doses of sodium bicarbonate may be given, 
20 or 30 grains (1.3-2.0) or more, after each meal. The following 
formula may be used: 

J$ — Magnesise (hydrated) 3 hiss (14.0) 

Bismuthi subnitratis . 3iiss (10.0) 

Cretae preparatse 3 hiss (14.0) 

Sodii bicarbonatis 3 iiiss (14.0). — M. 

Fiant in chartulas, No. xx. 

S. — One powder stirred in water three hours after meals. 

When the bromides are given, it is best to give them in solution. 
If the stomach is very irritable and there is a tendency to vomiting, 
a powder composed as follows is often useful: 

]} — Phenolis (cryst.) gr. xx (1.3) 

Bismuthi subnitratis 5 s s (15.0). — M. 

Fiat in chartulas, No. xx. 

S. — One t. i. d. with or before food. 

The symptoms manifested by the patients requiring this treat- 
ment are as follows: There is often a constant sense of gnawing 
or hollowness in the stomach, which is sometimes temporarily allayed 
by the taking of food. The patient is, as a rule, of a nervous temper- 
ament and often in a condition of nervous depression due to some 
exhausting cause. Tenderness and even pain in the epigastrium 
may be produced by superficial or deep palpation, or the patient 
may complain that the pressure of her clothes is distressing. If 
ulcer of the stomach is present, all the characteristic symptoms of 
that lesion may be found. When belching occurs, there is often 
vomiting of sour masses or acid eructations or heartburn. Gas- 
tralgia more or less severe may also occur. Sometimes such patients 
are neurasthenic and need a rest-cure. (See Gastric Ulcer.) Duo- 
denal ulcer or gall-stones may be the cause of great acidity. 

In cases where testing the stomach-contents show that the exces- 
sive acidity is not due to hydrochloric acid, but to the acids of fer- 
mentation, the use of the sedative drugs named is of no avail, for 
obvious reasons, and in their place sodium bicarbonate should be 
employed as a palliative, and antiseptic or antifermentative drugs, 
such as thymol, beta-naphtol, creosote, chloral, and sodium thio- 
sulphate, as direct remedial agents. Lavage of the stomach should 
also be resorted to. In still other cases a mixture containing chloral 
and thiosulphate of sodium is useful because of its antiseptic influ- 
ence. (See Chloral.) Often these cases are relieved if all fats are 
excluded from their diet-list. 

If much gas is developed and a sensation of weight in the stomach 
is felt after eating, so that the patient feels as if the food lay undi- 



INDIGESTION 839 

gested in that organ, the following prescription may be used, but is 
contraindicated if the stomach is tender on deep palpation, or, in 
other words, if acute irritation or inflammation of the stomach is 
present. It is useful in atonic states of the stomach, and it is sur- 
prising how much relief may be afforded by the use in such cases of 
these prescriptions: 

]$ — Oleoresinse capsici Tllij (0.1) 

Pepsini vel pancreatini gr. xx (1.3) 

Carbonis ligni gr. xl (2.6) 

Creosoti lllx (0.6).— M. 

Fiant pilulse, No. xx. 

S. — One after eating. 

Another useful formula is: 

1$ — Pulveris capsici gr. x (0.6) 

Extracti nucis vomicae gr. v (0.3) 

Taka-diastase 5ij (8.0). — M. 

Pone in capsulas, No. xx. 

S. — One with meals. 

Intestinal indigestion depends upon almost the same causes as 
does gastric dyspepsia, and is to be treated in much the same manner, 
chiefly by a careful study and regulation of the patient's diet, and 
by the use of a number of remedies calculated to aid to some extent 
the normal juices by some digestive ferment. These ferments 
should be given with the meals, or the food be "predigested" before 
it is taken. 

The pancreatin should be given in full dose (5 to 10 grains [0.3- 
0.6]), with bicarbonate of sodium, and alkaline mineral waters used 
if the urine is concentrated and acid. (See Biliousness.) 

Constant abdominal distress may be due to a diseased gall-bladder, 
a growth or to duodenal ulcer which demands surgical relief. 

Sometimes when intestinal indigestion is present great flatulence 
comes on, and is an annoying symptom. Very commonly in these 
cases it will be found that the patients think they have heart disease 
because of the pain they suffer under the precordium. This pain is 
due to the accumulation of flatus in the small intestine, or more 
commonly to its pressing upward at the angle where the transverse 
colon turns to go down to form the descending colon and sigmoid 
flexure. Under these circumstances the prescriptions named above 
will be found of service, or the following may be used: 

3— Acidi nitrici diluti f 3 ij vel 3 iij (8.0-12.0) 

Tincturae cardamomi composite . . . f§vj (180.0). — -M. 
S. — Dessertspoonful (8.0) in water four times a day. 

In some persons flatulence of the large bowel is met with, and 
is often associated with atony of the muscular coats of the gut. 



840 DISEASES 

Under these circumstances the following prescriptions will be found 
of service: 

1$ — Asafoetidae gr. xl (2.6) 

Extracti nucis vomicae gr. iv (0.25) 

Extracti physostigmatis gr. iij (0.2) 

Oleoresini capsici T([x (0.6). — M. 

Fiant pilulae, No. xx. 

S. — One pill three times a day, two hours after meals. 

Or, 

1$ — Tincturae belladonna? foliomm f5iij (12.0) 

Tincturae physostigmatis f3iss (6.0) 

Spiritus camphorae q. s. ad fgiij (90.0). — M. 

S. — Teaspoonful (4.0) two hours after meals or whenever needed. 

Abdominal massage is a valuable aid in treating this class of cases. 
Sometimes it can be well done by directing the patient to roll slowly 
and gently a three-pound cannon-ball over the course of the colon, 
to urge on the intestinal contents and cause secretion. In other 
instances the application of a roller electrode with the rapidly inter- 
rupted current from a faradic apparatus is useful. 

Where intestinal indigestion results in lientery the treatment 
becomes entirely changed, except in regard to the use of a predi- 
gested milk diet, and efforts must be made to increase the secretion 
of the glands of the intestinal wall. Often minute doses of mercury 
bichloride or podophyllin may do this, yo to ^ grain (0.001-0.0015) 
of the first or second, respectively. More commonly, however, the 
mixture of nitric acid, given above, will be the proper treatment or 
perhaps the following if the liver is found to be torpid : 

I^ — Acidi nitrohydrochlorici (not dil.) . . . f 3 ss vel f 3 J (2.0-4.0) 

Tincturae gentianae compositae . q. s. ad f$vj (180.0). — M. 
S. — Dessertspoonful (8.0) every four hours or after meals, in water. 

Chloroform spirit is often valuable in some of these cases in the 
dose of 1 dram (4.0) in water. (See Chloroform.) 

INFLUENZA. 

The disease known as influenza affects individuals so differently, 
and presents so many symptoms associated with functional disorder 
of various organs in the body, that it is almost impossible to do 
more than consider the remedies which are to be employed in the 
treatment of the more frequent or more immediate manifestations 
or complications. Of far greater importance than the employment 
of drugs must be regarded continuous rest in bed, and stimulants 
are in many cases essential. 

In those cases in which the disease is ushered in by a severe chill, 
accompanied by violent pains in the back and limbs, if the patient 
is seen early enough it may be necessary to employ remedies for the 
relief of the rigor, with the double purpose of improving the patient's 
general condition and preventing internal congestion of vital organs. 
In the majority of instances, however, the patient is not seen during 



INFLUENZA 841 

this period of the disease, but during the febrile stage, which succeeds 
that just mentioned. Under these circumstances the author does 
not believe that it is well for the physician to resort to any of the 
remedies which have been so largely used during the last few years, 
and which are known as the "antipyretics" or the derivatives of 
coal-tar. Although originally introduced for the purpose of reduc- 
ing febrile temperatures, practical experience has taught that their 
value is very limited under these circumstances, and the author never 
gives antipyrine, phenacetin, or acetanilid with the object of reducing 
fever. Although he does not believe that these remedies are to be 
used for the reduction of temperature, he has certainly seen very 
marked relief follow their employment with the object of subduing 
the severe pain which occurs in the back, limbs, or head. Small 
doses are usually sufficient at least to reduce the suffering, if not to 
remove it entirely, but, as cardiac complications are by no means 
unusual, large doses are contraindicated in most persons. The 
author prefers to allow the patient to suffer from a moderate degree 
of pain rather than from the dangers incident to the administration 
of doses large enough to relieve it entirely, because in his experience 
these doses have to be very large if they are to be entirely competent 
as analgesics in influenza. 

A very useful recipe in these cases is a capsule containing 5 grains 
(0.3) of aspirin and 3 grains (0.2) of cinchonidine sulphate. One of 
these must be taken every three or four hours. 

If any of the coal-tar products are used either for the relief of 
fever or of pain, phenacetin and acetanilid should be chosen. A 
favorite combination with practitioners who have had a large exper- 
ience is one of phenyl salicylate (salol) and phenacetin. The action 
of the phenacetin in relieving the pain and in reducing the fever 
seems to point to it as a rational remedy, but the exact influence 
of phenyl salicylate under these circumstances is not so clear. Com- 
posed, as it is, of 60 per cent, of salicylic acid and 40 per cent, of 
phenol, it seems to possess a therapeutical power different from that 
possessed by either of these two constituents alone, for neither 
phenol nor salicylic acid has much power in the relief of pain when 
used alone. Perhaps the condition of pain in the lumbar and other 
muscles during the attack of influenza is in some unknown way 
associated with the condition which has been called "rheumatism," 
and in which salicylic acid does good in an unknown manner. Sali- 
cylic acid alone might be equally useful if it were dissolved in the 
intestine and did not irritate the stomach. 

On seeing a case of influenza during the first few hours of the 
attack the author resorts to those remedies which have been in use 
by the profession for many years, and, so far, as he can learn, it is 
the custom of other members of the profession to give a mixture 
composed of spirit of nitrous ether and a solution of citrate of potas- 
sium in preference to any other medicine at this time. This mixture 



842 DISEASES 

possesses the advantage of increasing the action of the skin and 
kidneys, and of reducing the temperature, of quieting the circulation, 
and of being readily taken by the patient without danger of dis- 
ordering the stomach at this time or later, which is important as this 
organ is apt to become irritable. As a general rule, citrate of potas- 
sium is given in too small doses, and, unless there are reasons to 
the contrary, it should be given in the dose of 10 to 15 grains (0.6-1.0) 
three times a day to an adult. 

If the fever becomes excessive, so that there is danger of the 
patient suffering from a true hyperpyrexia, it is better to resort to 
cool sponging with active friction instead of the antipyretics just 
spoken of. It is a very important portion of this treatment to use 
frictions designed to bring the heated blood to the surface. (See 
Cold and Fever.) 

Hyperpyrexia in influenza does not seem to possess the same 
dangers that it does in the course of some other diseases. In the 
first place, as a general rule, the course of hyperpyrexia is very 
brief, and although it may leave the patient weak and exhausted, 
the duration of the febrile portion of the malady does not extend 
beyond a few days. Clinical experience and physiological study 
have proved that it is not the temperature of 105° or 106° F. which 
is distinctly dangerous, but the continuation of this temperature 
for many hours which is harmful. Similarly, a patient ill from 
typhoid fever, having a temperature of 103° for many days, is injured 
very much more than is a patient who is suffering from pneumonia, 
and who may have for forty-eight hours a temperature of 104.5° or 
105° F. For these reasons a temperature of 104.5° or 105° F. is 
not particularly alarming in the condition which we are considering, 
unless there are symptoms pointing to the fact that the patient is 
being injured by an excessive temperature, as may be indicated by 
somnolence and an exceedingly dry skin as well as cerebral symp- 
toms. The point to be strongly emphasized is that the mere exist- 
ence of high temperature is not to be regarded as a condition to be 
overcome by the use of drugs. 

It seems to be the general consensus of opinion, both in America 
and in England, that any measure of a depleting character are dis- 
tinctly harmful in influenza, even at its earliest stages, and we would 
naturally expect that this would be the conclusion arrived at by 
physicians who treat their patients rationally. Although influenza is 
a short-lived disease, there is probably no malady in which the 
patient goes so quickly into a condition of profound depression, or 
even exhaustion, as in this one. The abstraction of blood from a 
vein or by the use of wet cups for the relief of pulmonary congestion 
should not be resorted to, as it will increase the exhaustion. Before 
the system has a chance to recover from the onset of the attack it 
will be still further depressed by the therapeutic measures of the 
physician if he is unwise enough to bleed. 



INFLUENZA 843 

As the case of influenza progresses a condition of marked depres- 
sion, or even collapse, very frequently develops. The expression 
of anxiety on the patient's face is, to a physician who is accustomed 
to see it in other diseases, a most alarming symptom, and it is not 
until one has seen it repeatedly in influenza that he is able to give 
it its exact value. Associated with this condition, the skin is fre- 
quently covered with a profuse perspiration, and the pulse is apt to 
be very rapid, running, feeble, and easily compressed. At first 
glance the old saying, that "we treat the symptoms as they arise," 
would seem to cover to a very large extent the indications which 
are present at this period; yet the author's experience, which may 
differ from that of some of his readers, is that the cardiac stimulant 
which we are most frequently accustomed to use— namely, digitalis- 
does not seem to take hold of the circulatory apparatus and to act 
upon it in the manner which is desired. It may be that the pressing 
symptoms make us more anxious and impatient as to the use of 
any medicament, and that we do not have the patience to wait 
and allow such a slowly acting remedy as digitalis to take effect. 
Be this as it may, the author regards caffeine as infinitely preferable 
to fox glove when these symptoms appear; and he has been able 
to prevent their appearance, or at any rate to modify them to a very 
great extent, by using caffeine in full doses from the first portion of 
the stage of depression. As a general rule, caffeine is given in very 
much smaller doses than safety requires, and in many instances it 
fails to act because the doses are too small to combat the profound 
condition of exhaustion which is present. In an adult there is no 
reason why 3 grains (0.3) may not be given three or four times in 
twenty-four hours, and in some cases it may be given every four 
hours without producing any of the symptoms of an overdose. 
Divided doses are better than a few very large ones. 

In the employment of strychnine in influenza, the author knows of 
no better illustration of the fact that in some conditions drugs should 
be given for effect rather than in customary dose, and the physician 
who is timorous in the presence of depression, certainly does not 
lessen the patient's danger. As with all powerful medicaments, the 
action of the drug should be carefully watched, and at the first 
manifestations of muscular twitching or stiffness at the back of the 
neck its administration should be cut down or discontinued. In 
many instances where the collapse comes on suddenly the strych- 
nine should be administered hypodermically and followed by full 
doses by the mouth, in order to keep up the full effect upon the 
nervous and circulatory systems. In some cases it will be found 
that the bloodvessels seem to be so atonic that the strychnine is 
unable to produce a sufficient vascular effect to bring the patient 
out of his difficulties, and under these circumstances very good 
results follow the combination of atropine with strychnine, the 
atropine being a useful vasomotor stimulant under such circum- 



844 DISEASES 

stances. It also should be given in full doses for effect. As the 
acute stage of depression passes off the atropine should be stopped 
and the strychnine continued alone through convalescence. It is 
proper to point out, however, that strychnine is not suitable for 
the purpose of producing constant stimulation. It is a whip to the 
nervous system, and if used in too large a dose for too long a time 
the overwhipped system fags out. Under these circumstances it 
may cause an active delirium. Large doses should be used only for 
a day or two. 

Alcohol has not seemed to be of much value during the active 
period of the disease. In milk-punches and egg-nog it is, of course, 
useful during convalescence. 

When delirium comes on, it does not seem to be a symptom of 
very serious character either for immediate results or in influencing 
the prognosis as to the ultimate recovery of the case, and in cases 
of pneumonia complicating la grippe, in which delirium is the promi- 
nent symptom, it is not to be regarded in the same light as similar 
manifestations complicating ordinary pneumonia or other diseases. 
The delirium may be either talkative or muttering, but does not in 
the majority of cases require treatment, passing away with the fever 
and rarely extending into the stage of exhaustion. Barbital may be 
used as a sedative. 

For the irritative cough steam inhalations, laden in the first stage 
with benzoin or other innocuous and sedative substances, seem 
particularly useful. For the bronchitis which is often present it is 
generally sufficient to administer the ordinary mixtures, contain- 
ing ipecac and potassium citrate, in the earliest stages, and to fol- 
low them by chloride of ammonium or sandalwood oil in the later 
stages. The author does not think that the compound liquorice 
mixture containing antimony should be given in the second stage of 
influenza. A complication too apt to occur at this time is edema of 
the lung or a widespread bronchitis, with a profuse exudation which 
bids fair to drown the patient in his own secretions. Antimony 
is not only depressing to the circulatory and respiratory -systems, 
but also aids very materially in causing the peculiar excess of secre- 
tion which has just been spoken of. (See Bronchitis.) 

It may be necessary to use bromides if the cough is excessive, or 
to replace them by codeine or small doses of morphine. In many 
cases still better results will be obtained by a good preparation of 
cannabis, which may be pushed until it relieves the cough. 

(For the treatment of pneumonia see Pneumonia and below.) 

Vaccines have been largely used in prophylaxis. Their value is 
as yet uncertain. If possible a vaccine derived from the organisms 
producing the epidemic present should be employed as there seems 
to be reason for believing that it has a more specific effect. 

Vaccines have also been largely used in the treatment of the 
attack. I do not think the results obtained justify this. Indeed, 



INFLUENZA 845 

I believe that many cases are made worse by this procedure for the 
body is already so burdened with the infection that it fails to rally 
from the negative phase. 

The most promising method of treatment when this peculiar type 
of lobular pneumonia develops seems to be the use of the blood 
serum of a convalescent patient. Such a patient if robust before 
his illness may sometimes be bled to the extent of 600 cc and his 
serum used intravenously by separating it from the corpuscles or 
the whole blood given by the citrate method. (See Transfusion.) 
The quantity commonly given amounts to from 75 to 100 cc at 
a dose repeated once in twenty-four hours if need be. This injection 
may be followed by a sharp reaction characterized by a chill and 
sweat followed by an elevation of temperature but in the course of 
twelve or twenty-four hours the temperature falls nearly to normal 
and general improvement takes place in favorable cases. If the 
symptoms persist or return the dose is repeated as stated above. It 
is claimed by some French clinicians that there is no specificity in 
convalescent serum and that blood from any suitable healthy person 
is equally efficacious. The serum or blood should be injected gently 
and slowly. 

If sleeplessness is so pressing a symptom as to require attention, 
the bromides may be given, but it will be generally found that 
the insomnia comes after the attack rather than during it, or in 
any event it will not require attention until the patient is conva- 
lescent. Under these circumstances barbital, or barbital sodium, or 
even sulphonal (sulphonmethane) may be administered, care being 
taken in the case of sulphonal (sulphonmethane) that it is admin- 
istered in a powdered form or dissolved in hot water and given four 
or five hours before the time at which sleep is desired. 

For the vertigo and dizziness, which are sometimes bitterly com- 
plained of by the patient either during or after the attack, moderate 
doses of bromide of sodium with ergot or cannabis have seemed 
particularly valuable, probably because they exercise some effect 
upon the bloodvessels of the brain or its membranes or perhaps upon 
the bloodvessels of the ear. Certain it is that in those cases of tin- 
nitus not associated with organic change in the aural canals bromides 
and ergot do more toward relieving them than any other medication. 

In the constipation which is sometimes present in the early stages 
of influenza it is generally advisable to administer either castor oil 
or in other cases a bottle of the citrate of magnesium. A full pur- 
gative effect of any of the salines seems to lessen the fever when 
the bowels are unloaded. Care should be taken that the dose of 
the purgative is not excessively large, as it will weaken the patient. 
For the constipation following the attack probably no drug is so 
efficient as cascara sagrada, combined perhaps with aloin. (See 
Constipation.) If diarrhea supplants the constipation, the ordinary 
astringents, such as aromatic sulphuric acid and hematoxylon, will 
be found sufficiently active. (See Diarrhea.) 



846 DISEASES 



INSOMNIA. 

Insomnia is a condition complicating many diseases, and arises 
from such a host of causes that the physician may not be able to 
discover them for some days after the patient is first seen. As a 
general rule, a patient consulting a physician with this symptom 
expects a prescription to be given at once and the cause of the insom- 
nia found out afterward. Under these circumstances the physician 
may employ several drugs according to the information that he has 
concerning the patient's state. 

During the last few years a large number of remedies have been 
introduced as hypnotics, such as barbital, barbital sodium, paralde- 
hyde, chloralamide, sulphonal, trional, and others. Of these the 
best, from every point of view, are barbital, barbital sodium, dial, 
and sulphonal. The dose of barbital and barbital sodium is 5 to 15 
grains (0.3-0.6), best given in capsule or hot water, and of sulphonal 
the dose is 10 to 20 grains (0.6-1.3), but as it is large in bulk, it should 
be used in a prescription made up as follows : 

1$ — Sulphonal (sulphonmethani) ...... gr. xxx (2.0) 

Syrupi . . f 3ij (8.0) 

Mucilaginis acacise f 3ij (8.0) 

Aquse destillatse q. s. ad f 5 j (30.0).— M. 

S. — From half to all of this at one dose, as may be needed. 

In other instances sulphonal may be dissolved in very hot water or 
milk, and the solution swallowed before it cools sufficiently to permit 
precipitation. 

One of the most common remedies is hydrated chloral given in 
the following manner: 

B— Chlorali hydrati 5hj (12.0) 

Syrupi f3iv (16.0) 

Aquse cinnamomi q. s. ad f giij (90.0). — M. 

S. — Dessertspoonful (8.0) at night. 

Or, 

I$— Butyl-chlorali hydrati 3J (4.0) 

Fiant pilulse, No. xii. 

S. — One, two or three pills at night, as needed. 

Where, for any reason, as the presence of a weak heart, chloral 
is contraindicated, resort may be had to the bromide of strontium, 
or sodium, and if the patient is a woman these drugs should always 
be accompanied by a small dose of arsenic, generally in the form of 
Fowler's solution, 1 to 3 minims (0.06-0.2) three times a day in 
order to avoid the possibility of the production of acne. The fol- 
lowing prescription is useful: 

I^— Strontii bromidi 3 ij vel 5 ss (8.0-16.0) 

Liquoris potassii arsenitis f 3ss (2.0) 

Aquse cinnamomi . . . . q. s. ad fgvj (180.0). — M. 

S. — One or two dessertspoonfuls (8.0-15.0) at night. 

In many cases larger amounts of the bromide will be needed. 
Where the sleeplessness is due to pain, chloral is of little value and 



INSOMNIA 847 

bromides are worthless. Under these circumstances by resorting 
to what is known as the "crossed action of drugs/' we can often 
obtain a very good effect. Thus morphine and chloral both act on 
the brain to produce sleep, or, in other words, their action is here 
crossed, for one relieves pain and the other does not; one kills by 
failure of the heart in overdose, the other by respiratory failure; as 
a consequence large doses of neither can be given alone. The fol- 
lowing is therefore a useful combination, either where one drug 
fails or when dangerously large doses of either alone have to be 
used to obtain the desired result: 

1$ — Morphinse sulphatis gr. ij vel iv (0.12-0.25) 

Chlorali hydrati 3ij (8.0) 

Syrupi fgij (60.0) 

Aquas q. s. ad fgiv (120.0). — M. 

S. — Dessertspoonful (8.0) at night. 

In cases where insomnia is due to mania hyoscine is very useful, 
particularly when combined with morphine, given in the dose of Tiro 
to 9-V grain (0.0006-0.0007) by the mouth or ^ grain (0.0006) 
by the hypodermic needle. Owing to its tastelessness the powder 
may be put on the tongue, and it is best to order a little sugar of 
milk or white sugar (1 grain) to be added to each dose of hyoscine, 
in order to give it bulk. 

When insomnia follows mental effort, avoidance of all cerebral 
activity should be insisted upon during the evening, and if the feet 
are cold on going to bed, sleep should be induced by relieving the 
cerebral congestion by a hot foot-bath or the use of a hot-water bag 
at the feet while cold is applied to the head. In other instances a 
general hot bath, during which an ice-bag is applied to the head, 
will produce sleep when drugs fail; and it is to be remembered that 
in the insomnia of convalescence and neurasthenia hydrotherapeutic 
measures are to be used to the exclusion of drugs (see Cold and 
Heat), for the former cure the condition, while the latter only palliate, 
and may produce a drug-habit. 

Not infrequently patients convalescing from prolonged illness 
suffer from drowsiness during the day and wakefulness at night 
because the circulation is feeble and fails to supply the brain with 
blood while the body is erect, but does so very well when recumbent. 
Hydrotherapy to improve the vascular tone and the use of a pill of 
nux vomica and arsenic, or nux vomica and phosphorus, is useful 
in these cases. 

In ordinary nervous insomnia or that due to heart disease, chlore- 
tone often acts very efficaciously in the dose of 5 to 10 grains (0.3- 
0.6); in tablets or capsules of 3 to 5 grains (0.2-0.3) each. 

Chloralamide (Chloralformamidum) sometimes does good in the 
dose of 15 to 60 grains (1.0-4.0), dissolved in wine or given in capsule. 
Paraldehyde is given in the dose of 20 to 60 minims (1.3-4.0). It is 
very apt to disorder the stomach, but it acts promptlv. (See Part 

id 



848 DISEASES 

In the treatment of insomnia it should be remembered that if 
possible those drugs should be used which will quiet the part of 
the brain which is most active. Thus if the patient is restless, bro- 
mides and chloral should be used as motor depressants. If sensation 
is acute, bromides and the hot pack may be used as sensory quietants. 

In some cases horseback exercise taken late in the afternoon does 
good, particularly if the patient follows a sedentary life. Care must 
be taken to avoid excessive fatigue. Many persons who are usually 
sleepless will obtain a refreshing slumber by taking a very light and 
easily digested meal just before retiring for the night or by eating a 
cracker or drinking a glass of milk when they awake during the night. 

In some instance sleeplessness arises from acidity of the stomach, 
and is put aside by the use of bicarbonate of sodium. 

INTERMITTENT AND REMITTENT FEVERS. 

It having been proved that malarial fever is always the result of 
the bite of a mosquito, the disease is to be prevented by removing 
mosquito-breeding pools and by protecting the skin. It is also 
important to prevent mosquitoes from biting a patient with malaria, 
as by this means the infection is spread. Such patients should sleep 
under a netting. 

The diagnosis of "malaria" followed by the use of quinine has in 
the past been one of the abuses of medical practice. At present, 
even allowing for the unusual manifestations of this infection, the 
use of the microscope makes the diagnosis and the therapeutics 
sure. The diagnosis is, of course, clinical as well as microscopic and 
the special parasite in a given case is indicated by the symptoms as 
well as by the microscope. 

The Tertian Parasite.— The tertian parasite clinically produces a 
sharp temperature rise introduced by a chill. This is followed by 
a sweat and a fall to normal or subnormal. The whole attack is 
usually over in eight hours and recurs, as the name of the parasite 
indicates, every third day. Microscopically this parasite is the 
largest of the three plasmodia. The Plasmodium vivax is found in 
the peripheral blood in all its stages from the small rings to the 
adult sporulating organism. The red cells which are infected are 
strongly stippled and are large and swollen in appearance. The 
spores when set free are larger than the spores of the malignant 
form. The tertian parasite is always the most prevalent in the 
temperate zone. 

The Quartan Parasite.— The quartan parasite (Plasmodium malarioe) 
clinically produces short, sharp attacks like the tertian; except, as 
its name indicates, the attacks occur every fourth day. The disease 
is usually mild in its manifestations but is more resistant to quinine 
and more prone to relapse than the ordinary tertian or malignant 
estivo-autumnal parasite. Microscopically it does not enlarge the 



INTERMITTENT AND REMITTENT FEVERS 849 

corpuscles as does the tertian and the intracorpuscular movements 
of the parasite are not so marked. 

The Mstiw-autumnal or Malignant Tertian Parasite.— Clinically 
the rise of temperature may be as prompt but there is then a slight 
abortive fall followed by a rise so that the attack lasts eighteen to 
twenty hours instead of eight. The rigors are, as a rule, less marked 
than in ordinary tertian. The patient is manifestly severely ill (see 
below). Microscopically this organism (Plasmodium falciparum) is 
found in the peripheral blood only during the young or ring stage. 
The red cells which are involved are shrunken, not swollen, and have 
a metallic appearance and they are not stippled. Sporulation is not 
often seen as it does not take place in the peripheral blood but in 
the capillaries of the viscera. Repeated examinations may therefore 
be necessary to find the parasite. 

Finally the examination of the white cells will give much valuable 
collateral diagnostic evidence. Thomson states that malaria is the 
only disease in which the leucocytes of the peripheral blood contain 
dark brown pigment granules and this is particularly true of the 
large mononuclear cells. There is a relative increase in the mono- 
nuclear cells particularly between the paroxysms, but there is a 
general leucopenia except when the comatose type of malignant 
infection is present, when there may be a leucocytosis of 100,000 
(Thomson) . A polymorphonuclear leucocytosis indicates no malaria 
unless there is an inflammatory complication. (For the changes 
produced in these parasites by quinine see Cinchona in Part II.) 

In all forms of intermittent fever, whether the attacks are quotid- 
ian, tertian, or quartan, the best remedy for their prevention is 
quinine, which if given by the mouth should be administered about 
two or three hours before the attack is expected, so as to be absorbed 
and be active when sporulation takes place. This precaution is 
often overlooked, and the dose ordered at the time of the expected 
attack, with failure as a result. Not only should sufficient time 
elapse for absorption, but the fact should be remembered that the 
chill often begins an hour earlier each day, and will be in full sway 
before the quinine can stop it if the drug be not administered at 
the proper time. 

Two methods of giving quinine in malaria have been employed. 
In one it is given just before an expected paroxysm, to prevent it by 
destroying the parasite at the time of maturity. In the other plan 
the drug has been administered in the sweating stage, not because 
it will have any valuable influence on that particular paroxysm— 
which is nearly over— but in order that it may destroy the young 
spores which are floating free in the blood-stream and about to 
attack corpuscles, in which they will mature. Undoubtedly if the 
quinine is given at the proper time before an attack it tends not only 
to prevent the oncoming paroxysm, but also future ones by its 
influence upon the mature and immature parasites. If, therefore j 
54 



850 



DISEASES 



the patient is seen before the attack, he should receive quinine to 
prevent or modify it. If seen after an attack is well advanced, he 
should receive the drug to prevent the next attack by destroying 
the crop of parasites set free in the blood during the paroxysm just 
passed. 



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Fig. 135. 



-Typhoid fever convalescence complicated by malarial tertain parasite in 
blood. Cured by quinine. 



In other words, quinine should be given freely daily until the 
infection is eradicated in order that any double infection may be 
overcome, that no immune parasites may be developed, and that 
the sexual form of the parasite, which does not produce a paroxysm 
but infects mosquitoes which spread the disease, may not develop. 
The best method if the quinine is given orally is to administer 10 
grains (0.65) t. i. d., for several weeks, even if the patient seems well 
after a few days. (See also intravenous use under Cinchona.) 

Experience has proved that quinine never acts as favorably if 
constipation is present as when the bowels are lax, and hepatic 
activity seems particularly necessary for its full effect. To obtain 



INTERMITTENT AND REMITTENT FEVERS 851 

the full influence of the drug, it should be preceded, by some four 
or five hours, by 1 grain (0.06) of calomel every fifteen minutes until 
5 grains (0.3) are taken, or by 5 or 10 grains (0.03-0.65) of blue mass, 
or by a dose of podophyllin amounting to yg- to J grain (0.006-0.008). 
If the podophyllin is used, a longer time should be allowed, because 
of the slow action of this purgative, and if the patient has been 
rendered unusually insensitive to purgatives, larger doses of both 
the remedies named must be used; particularly is this true in the 
hot climates, where 5 to 20 grains (0.3-1.3) of calomel are often used 
and really needed. 

The dose of quinine varies with the exigencies of the case, which 
in turn generally depend upon the region in which the patient lives 
or has lived. If the patient remains in bed, smaller doses are needed 
than if he remains up and about; 10 to 15 grains (0.6-1.0) in one 
dose are often sufficient in the eastern and northern States, but as 
much as 20 'to 45 (1.3-3.0) or even 60 grains (4.0) may be required 
in the southern and southwestern parts of the United States and 
elsewhere. Unless the condition is very grave, however, these 
amounts are best given in divided doses every few hours. The 
same dose is to be repeated daily until no parasites can be found 
in the blood, and if the attacks do not recur, it is wise to repeat the 
dose of quinine every week for several weeks to avoid relapse. Medi- 
cation by the mouth may fail because of slow absorption or partial 
destruction of the drug in the liver. It is important to remember 
that while small doses may seem to cure the patient by preventing sporu- 
lation and the development of chills and fever, they may not destroy 
those parasites which hide in the spleen and bone-marroio where they 
gradually become immune to quinine. If the drug is stopped too soon 
they return to the blood-stream, sporulate, and may be difficult to 
kill unless they are attacked by intramuscular or intravenous doses 
or by the use of arsphenamine. 

It is noteworthy that no less an authority than Sir Ronald Ross 
advocates the use of about 8 grains a day in chronic malarial infection 
divided into four doses continued for at least as long as four months, 
even if the blood shows no parasites, because he believes single very 
large doses tend to overwhelm the body which hurries to eliminate 
them, with the result that many of the more deeply situated parasites 
escape the drug. In other words he advocates prolonged moderate 
doses rather than a few heroic ones. 

When an immediate and certain effect is essential, quinine should 
be given intravenously. (For the best salts of quinine for intra- 
venous use, see article on Cinchona.) 

Having considered the prophylaxis of a chill, let us turn to the 
treatment of the attack itself. It must be remembered that the 
greater part of the harmful effect of the malarial poison is exerted 
at this time by the internal congestions and engorgement of the 



852 DISEASES 

abdominal and thoracic organs. The physician should therefore 
try to prevent so far as possible too great a rigor; and if stasis results 
from the chill, overcome it, not by depletants, but by stimulants, 
such as strychnine or digitalis, which will drive out the blood from 
the congested area. 

If a full meal has just been eaten, the stomach should be emptied 
by an emetic dose of ipecac, 2 drams (8.0) of the powdered drug to 
an adult, or by J grain (0.006) of apomorphine. It is almost useless 
to give quinine at this time, as absorption from the stomach and 
subcutaneous tissues is almost entirely absent. Alcoholic stimu- 
lants are not to be employed, as clinical experience seems to indicate 
that they do not act favorably. 

If the chill is severe enough to endanger the patient's life, meas- 
ures must be used to control it. Chloroform may be inhaled, and 
immediately preceded by laudanum by the bowel or mouth. If 
the laudanum is given by the mouth, a little ether or chloroform 
may be added to the dose of the opiate. The opium may be used 
hypodermically in the form of morphine in the dose of § grain (0.01) 
combined with ^ grain (0.001) of atropine. 

In the fevered stage little can be done except to give the patient 
comfort by cool drinks and cool sponging, or, if the fever becomes 
excessive, by the use of ice-cold sponging with active friction. These 
measures have seldom to be used, as the fever is generally too fugitive 
to need such treatment. 

The sweating stage needs no particular treatment unless exhaus- 
tion is caused by it, when stimulants may be cautiously used as 
needed, and large draughts of water at ordinary temperatures 
swallowed. 

Pernicious Malarial Fever. 

This is one of the most acute and dangerous infections if it be fully 
developed, and requires the greatest activity and skill on the part 
of the physician, who may be called upon to treat a large number of 
widely varying symptoms, all of a pressing nature, at one and the 
same time. The chief indication is for the use of quinine in its most 
soluble forms, in solution and in large doses, which may be given 
intramuscularly or intravenously. (See Cinchona.) 

As a rule, the use of the drug by the mouth is futile because the 
state of the stomach is such that absorption will not take place in 
time to be of any service. The intravenous use of the drug is there- 
fore advisable. Given in this manner, doses ranging from 10 to 
15 grains (0.6-1.0) may be used at each dose with safety. If more 
than this is given intravenously, the dose must be given very slowly, 
and preferably divided into several smaller doses lest cardiac depres- 
sion ensue. If the attack be of the hematuric or hemoglobinuric 
type, quinine is to be used with the greatest caution 3 and not at 



INTERMITTENT AND REMITTENT FEVERS 853 

all unless the malarial organism can be found in the blood. (See 
Cinchona.) The patient may be treated by the use of 60-grain 
(4.0) doses of thiosulphate of sodium every two or three hours until 
the bowels are moved freely in such cases. Copious draughts of 
pure water, with or without lemon-juice added, are to be given to 
flush the kidneys, and if necessary morphine and atropine are to be 
given hypodermically to control the retching and vomiting. 

Remittent Fever. 

This is sometimes called bilious fever by reason of the violent 
bilious vomiting and jaundice which often accompany it. It sepa- 
rates itself from intermittent fever by the fact that the patient's 
condition, chiefly as regards temperature, does not have normal 
intervals, but has periods of only temporary improvement, or in 
other words, the disease remits. 

For the proper treatment of this fever, three facts must be borne 
in mind: (1) It is more dangerous than intermittent fever. (2) The 
patient, not having periods for complete or partial recovery, rapidly 
loses strength. The safety of the patient depends upon the use of 
large doses of quinine to cut short the pyrexial stage, the doses used 
being from 20 to 30 grains (1.3-2.0) a day or 5 grains (0.3) every 
four hours, preceded by a good-sized purgative dose of calomel, say 
3 or 4 grains (0.2-0.25). If vomiting is too violent to permit of the 
retention of the quinine, it must be used intravenously, the stomach 
and intestines being first swept out by the use of divided doses of 
Seidlitz powder or citrate or sulphate of magnesium. (See Cin- 
chona.) If purgatives are used, they should precede the quinine 
by sixty minutes, as otherwise the latter drug is swept out in the 
bowels, where it it is rendered useless by reason of its precipitation 
by the alkaline juices there present. If pyrexia is excessive, relief 
must be sought in the use of cool sponging with friction. Cure is 
much facilitated by absolute rest in bed. 

A good treatment of the vomiting is the use of small doses of 
morphine, or 3- to 5-minim (0.2-0.3) doses of chloroform, in com- 
pound tincture of lavender and water. (See Vomiting.) 

If the belly is tender, a turpentine stupe should be applied. (See 
Turpentine.) 

If hematuria appears and the malarial parasite is found in the 
blood, quinine must be used, but it should be remembered that 
quinine in some cases increases the hematuria. (See Cinchona and 
Collective Investigation by author in Therapeutic Gazette, July, 1892.) 

The treatment of convalescence consists in the use of tonics, such 
as quassia, calumba, gentian, Huxham's tincture, arsenic, and pur- 
gatives when needed, with attention to the kidneys, the potassium 
salts being employed to keep these organs active. 



854 DISEASES 



IRITIS. 



Iritis, or inflammation of the iris, as usually encountered, is caused 
by syphilis, gonorrhea, tuberculosis, local septic areas, and certain 
diseases of nutrition, for example, gout and diabetes. It may also 
be traumatic. It is practically never observed in acute rheumatic 
fever, but often arises in the subjects of so-called chronic rheumatism 
and muscular rheumatism, the iritis and the general disease in all 
probability being due to the same as yet unknown cause. Many 
types of iritis, iridocyclitis, or uveitis are due to bacterial infections 
arising from local septic areas, for example, pyorrhea alveolaris, 
tooth-root abscess, accessory sinus disease, infected tonsils, and 
intestinal putrefaction, the inflammation being called into existence 
by the microorganisms themselves or their toxic products. Metas- 
tatic iritis occurs in pyemia and in a number of infectious diseases, 
for instance, recurrent fever, variola, influenza, etc. The most 
marked symptoms of ordinary iritis are severe brow pain; fine ciliary 
injection; discoloration of the iris and immobility of the pupil, due 
to the formation of adhesions between the iris and the capsule of 
the lens, the so-called posterior synechia. The most important 
local remedy is atropine (4 grains to 1 fluidounce), one drop to be 
used every four hours, according to circumstances. If for any reason 
this remedy is not tolerated, duboisine, scopolamine, or daturine 
(2 grains to 1 fluidounce) may be substituted. Great care must be 
taken not to mistake iritis for conjunctivitis, on the one hand, and 
glaucoma for iritis, on the other; delayed use of atropine and the 
employment of astringents on account of the former error, or the 
instillation of atropine because of the latter, would constitute a 
serious therapeutic blunder. 

Pain may be relieved by leeches to the temple and the use of dry 
heat externally (cotton batting heated over a radiator will suffice), 
or hot compresses composed of lint, soaked in water at a tempera- 
ture of 110° F., frequently changed. In traumatic iritis iced com- 
presses are of service. Usually they are not satisfactory in those 
forms of iritis which depend upon constitutional disturbance. In 
uveitis (sometimes called serous iritis), or that disease in which there 
is a hypersecretion of the aqueous humor, which becomes turbid 
and a precipitate of dark spots is deposited on the membrane of 
Descemet, there must be constant observation of the effect of the 
atropine, inasmuch as there is frequently a tendency to increase 
of the intra-ocular tension. Should this occur, paracentesis of the 
cornea may be required. Free sweating, either with the aid of 
hypodermic injections of pilocarpine or by means of an ordinary 
electric cabinet, is efficacious, as, indeed, it is in many forms of 
iritis. 

Uveitis depends upon the same causes which are active in the 



IRITIS 855 

production of ordinary iritis, and its chronic varieties are often due 
to tuberculosis, and in these circumstances injections of tuberculin 
are to be commended. 

In certain forms of iritis, particularly the stubborn and relapsing 
varieties, subconjunctival injections have been highly commended, 
for example, cyanide of mercury (1:5000), a few drops of a 1 per 
cent, solution of acoine being added to the injection in order to miti- 
gate the pain. From 10 to 15 minims of the cyanide solution may 
be injected subconjunctivally. Similar injections of physiological 
salt solution are equally efficacious and preferable because they 
cause less pain. The relief of pain in all forms of iritis constitutes 
an important part of the treatment; hypodermic injection of mor- 
phine is perfectly justifiable in emergencies, but must not be repeated 
too frequently. Hyoscine, yjq to yio of a grain, at night, is a valu- 
able remedy. Locally, dionin (5 per cent, solution) is of distinct 
value; it stimulates lymphagogue activity and causes somewhat 
prolonged local analgesia. It may be combined with atropine in 
the usual strength and reinforced with a 2 per cent, solution of 
holocaine. 

In all forms of iritis it is important to determine the presence of 
the constitutional disease, or the area of local sepsis (focal infection) 
which is the source of the disease. Therefore a Wassermann test 
and a tuberculin test should be instituted. Teeth, tonsils, accessory 
sinuses, etc., should be examined and pathological conditions cor- 
rected and search made for septic foci by x-ray examination of the 
teeth and sinuses. 

If the cause of the iritic inflammation is syphilis, mercury should 
be pushed to the point of tolerance, but it is not necessary to salivate 
the patient. Any form of mercury usually employed in secondary 
syphilis may be used— calomel, blue mass, or protiodide of mercury; 
very efficacious are inunctions of unguentum hydrargyrum, 1 dram 
daily preceded by a hot pack, as are also hypodermics of salicylate 
of mercury. In all types of syphilitic iritis arsphenamine and neo- 
arsphenamine yield admirable results, and under their influence the 
lesions disappear with surprising promptness. During the intervals 
between the injections mercury and iodide of potassium may be 
administered. Mercury is a valuable remedy in non-syphilitic iritis, 
acting as a powerful alterative. Potassium iodide, either alone or 
in combination with bichloride of mercury, is frequently employed. 
In so-called rheumatic iritis, or that form of the disease which appears 
in the subjects of chronic rheumatism, muscular rheumatism and 
polyarthritis, salicylate of sodium should be administered in full 
doses, or aspirin may be employed in its place. Potassium iodide 
is a proper remedy in gonorrheal iritis, and this form of the disease 
often responds satisfactorily to profuse diaphoresis. Excellent results 
follow the use of Neisser's bacterin. Naturally, such regulation of 



856 DISEASES 

diet and such remedial agents as are indicated by the various other 
causes of iritis, for example, gout, diabetes, and the like, must receive 
full consideration, if examination has proved these factors to be 
etiologically active. During the course of iritis the condition of the 
alimentary canal should receive strict attention, and often a course 
of saline laxatives is followed by excellent results. In certain forms 
of iritis, bacterial in origin, especially if the microorganism can be 
isolated from an area of local sepsis which is furnishing the infecting 
agent, autogenous vaccines have achieved admirable results. In 
every case of iritis, or uveitis, the elimination of focal infection is 
an imperative part of the treatment. In chronic iritis, and in some 
forms of relapsing iritis, iridectomy is required to reopen the angle 
of the anterior chamber which has been closed by inflammatory 
exudations, in order to prevent secondary glaucoma. 



KERATITIS. 

Keratitis is the name applied to the various types of inflammation 
of the cornea. If this inflammation is associated with a breach in 
the continuity of the corneal surface, it is termed corneal uher, 
and photophobia, or dread of light; blepharospasm, or spasmodic 
contraction of the orbicularis muscle; congestion of the bloodvessels; 
and pain are constant symptoms. 

Interstitial Keratitis. 

Interstitial keratitis is that form of chronic diffuse inflammation 
of the cornea characterized by ciliary congestion and a ground-glass 
appearance of this membrane, most common between the ages of 
five and fifteen years, and in the majority of cases the result of 
inherited syphilis. In from 2 to 10 per cent, of the cases acquired 
syphilis is the etiologic factor. No local measure is sufficient, anti- 
syphilitic treatment being of paramount importance. Arsphena- 
mine and neoarsphenamine are valuable in syphilitic cases. During 
the height of the ciliary congestion warm antiseptic lotions and 
atropine are indicated, the latter especially to prevent the tendency 
to iritis. Severe pain may be alleviated by the use of a leech to the 
temple if the subject is sufficient age to justify the employment of 
local bleeding. Dionin is of value. Similar forms of keratitis are 
caused by rhachitis, tuberculosis, myxedema and depressed nutri- 
tion. In addition to the local measures already described, the 
appropriate constitutional remedies are required, particularly iron, 
arsenic, cod-liver oil, and the iodides. Suitable dietetic and general 
hygienic measures are important, and in tuberculous cases injections 



KERATITIS 857 

of tuberculin are efficacious. Patients with interstitial keratitis 
should be subjected to Wassermann and tuberculin tests. 

Various other types of keratitis are described as the result of 
constitutional disturbances, such . as gout (Hutchinson), malaria 
(Kipp, van Milligen), or any condition of the system associated with 
great exhaustion, such as irregularities in the menstrual function, 
certain forms of pulmonary disorders (true herpes of the cornea, 
Horner) . The local management of these cases does not differ from 
that which has been described. The coexisting constitutional dis- 
turbances must be combated with suitable remedies. Parenchy- 
matous keratitis apparently is due in some cases to defective intestinal 
function and autointoxication. Some forms are the. result of focal 
sepsis in the buccal mucous membrane and some types result from 
traumatism. 

Phlyctenular Keratitis. 

Phlyctenular keratitis appears in the form of small, blister-like 
bodies, sometimes single, sometimes multiple, frequently situated 
directly at the corneo-scleral margin, which become yellow, break 
down, and leave an open ulcer (phlyctenular ulcer), to which runs 
a leash of injected bloodvessels. The disease is common in children, 
often follows in the wake of the exanthemata, and is so frequently 
associated with a so-called strumous diathesis that it was formerly 
called strumous ophthalmia. The clinical association between this 
disease and eczema of the face and scalp is an intimate one. In the 
majority of cases there is coexisting nasal disease, especially adenoid 
vegetations, which is responsible for the frequent relapses of the 
disorder, even if they do not cause it. Congestion may be relieved 
by frequent irrigation with a warm boric-acid solution. Pain and 
irritation call for the use of atropine drops (4 grains to the ounce 
[0.25-30.0]), which should be continued until the ulcer is covered 
with regenerated epithelium, when the process of cicatrization may 
be hastened by the insertion daily into the conjunctival sac of a 
small quantity of yellow oxide of mercury salve, or dusting it with 
finely powdered calomel, providing the patient is not taking at 
the same time any form of iodine. During the whole treatment the 
eyes should be protected by dark glasses and the subject permitted 
to go out into the open air. All local treatment will prove unsatis- 
factory unless associated with strict hygiene, carefully regulated diet, 
and constitutional measures— tonics and alteratives— and treatment 
of the nasopharyngeal lesions. 

The evidence is daily increasing that phlyctenular keratitis is 
closely connected with tuberculosis and probably caused by it. 
Hence its subjects, especially in dispensary service, should be treated 
like other cases of tuberculosis, viz., after the patient is instructed 
as to general living, proper food, etc., he is visited by one of the 



858 DISEASES 

workers in the social service of the hospital, and is shown how to 
live and helped to carry out all directions. 

If the photophobia becomes distressing in spite of the other treat- 
ment, it has been suggested that this may be relieved by the use of 
cocaine, a practice that by no means commends itself in corneal 
ulceration, in spite of the temporary relief from local anesthesia. 
Holocaine (2 per cent.) may be employed. Relief of this symptom in 
many instances follows the use of a douche of cold water on the 
closed eyelids, or by touching with blue-stone the ulcerated fissure 
at the external commissural angle, which is commonly an exciting 
cause of the spasmodic closure of the lids. 

Ulcerative Keratitis. 

Ulcerative keratitis, or ulcers of the cornea, may be primary in 
origin— that is, the disease begins in the cornea— that may be caused 
by phlyctenular disease, injury, abscess, depressed nutrition, etc.; 
or may be secondary, and result as the sequel of severe inflammations 
of the conjunctiva: for example, purulent, diphtheritic, or granular 
conjunctivitis. There are numerous varieties of corneal ulcers, but 
three groups only will be mentioned: simple ulcers, which form a 
small, superficial gray lesion, and are not accompanied by much vas- 
cularity or dread of light; purulent or deep ulcers, in which the 
open lesion is of yellowish color and is surrounded by hazy cornea; 
and infecting or sloughing ulcers (purulent keratitis), in which the 
ulcer assumes a serpiginous or creeping form, and there is usually a 
deposition of pus in the bottom of the anterior chamber (hypopyon 
keratitis). Typical serpiginous ulcer of the cornea with hypopyon 
is frequently caused by the Frankel-Weichselbaum capsulated diplo- 
coccus; that ulcers not typically serpiginous may originate from a 
staphylococcus, streptococcus, or mixed infection; and that a small 
percentage of sloughing keratitis is due to a schizomycetal infection— 
the aspergillus fumigatus. Other active organisms are Bacillus coli, 
Bacillus pyocyaneus and diplobacilli, especially Morax-Axenfeld 
diplobacilli The various microorganisms come from the conjunctiva, 
the ciliary borders, the nares, and the lacrimal passage, and infect 
some slight abrasion on the corneal epithelium and thus start a 
dangerous form of suppurative keratitis. An abscess of the cornea 
may also occur as the result of an inoculation of the infected area 
with pathogenic microorganisms, typical forms sometimes appearing 
during scarlet fever, measles, typhoid and typhus fevers, and espe- 
cially during the convalescent stage of smallpox. Infected ulcers 
may be caused by microorganisms from areas of local sepsis in the 
gums as pyorrhea alveolaris. Simple corneal ulcers are treated in 
precisely the same manner, as phlyctenular ulcers. The treatment 
of severe ulceration of the cornea, no matter what its etiology, may 
be summarized as follows: (1) Search should be made for the cause 



KERATITIS 859 

of the ulcer, including careful examination for the presence of a 
foreign body, a misplaced cilium, conjunctival inflammation, lacri- 
mo-nasal disease, affections of the rhinopharynx, oral sepsis, and 
constitutional disorders of all types. The active microorganism 
should be determined by appropriate bacteriological examination. 
(2) At frequent intervals moist heat should be applied by means of 
lint or flannel compresses dipped in water at a temperature of 120° 
F. (3) Unhealthy conjunctival discharge should be removed by 
frequent irrigations with mercuric chloride (1:8000), or a saturated 
solution of boric acid. Protargol (10 per cent.) and argyrol (25 per 
cent.) are also used. Care must be taken lest they stain the affected 
corneal tissue. (4) Sterile atropine drops (4 grains to the ounce 
[0.25-30.0]) should be instilled with sufficient frequency to maintain 
mydriasis if there is any tendency to iritis, and dionin (5 per cent.) 
is of great service. In the opinion of some surgeons, eserine (i to J 
grain to the fluidounce') is a useful drug in the treatment of peripheral 
ulcers with a tendency to perforate the cornea, provided there is 
no iritis. Occasionally the tension rises; if so, myotics are indicated 
or paracentesis of the cornea. (5) The eyes should be protected 
with smoked glasses; but in severe cases and in the absence of puru- 
lent conjunctival discharge a dry antiseptic dressing, held in place 
by a light but firmly applied bandage, promotes healing and pre- 
vents perforation. It may be worn until the floor of the ulcer is 
covered with epithelium, and removed whenever the applications are 
required. A little iodoform may be dusted upon the surface of 
the ulcer before the bandage is applied, or the ulcer may be covered 
with an iodoform wafer. If the Morax-Axenfeld bacilli are present 
the ulcer should be touched with a 1 per cent, solution of zinc sul- 
phate. (6) If the ulcer shows a tendency to spread rapidly, it should 
be curetted and immediately afterward gently touched with a 
probe which has been dipped in pure phenol, or with a wisp of cotton 
which has been dipped in a solution of nitrate of silver (10 grains 
to the ounce), tincture of iodine, or trichloracetic acid. Of these 
remedies nitrate of silver and tincture of iodine may be used in ulcers 
of the non-infective type; but in ulcers of the infective variety pure 
phenol or trichloracetic acid, should be employed. (7) If the ulcer 
continues to spread, the actual cautery may be used, the glowing 
point of the cautery needle being applied to every portion of the 
ulcer, the area of which is outlined by means of fluorescine (2.5 per 
cent solution), which will color green any portion of the cornea 
deprived of its epithelium, and therefore furnish a reliable guide to 
the extent of the destructive process. Before these severe applica- 
tions are made the cornea should be rendered insensitive by a few 
drops of a holocaine solution, and the ulcer itself painted with a 
cotton wisp dipped in holocaine. Indeed, there is much evidence 
to show that the application alone of this drug has a distinctly cura- 
tive influence on corneal ulcers, in this respect differing very dis- 



860 DISEASES 

tinctly from cocaine, which rather retards the cicatrizing process. 
Subconjunctival injections of cyanide of mercury (1:5000) or of 
physiological salt solution at times yield satisfactory results. If an 
abscess forms in the cornea, the pus should be evacuated by an 
incision; and hypopyon, or pus in the anterior chamber, may be 
drained by an operation after the manner devised by Guthrie— 
that is, by division of the corneal layers— or, by a simple paracentesis 
of the cornea. Of great value in the treatment of infected corneal 
ulcer is the method often called " pasteurization," whereby the 
glowing blade of an electrocautery is passed over the ulcerated 
area and close to it, but does not actually touch the ulcer. 

For the relief of infected ulcer of the cornea due to the pneumo- 
coccus, Roemer's antipneumococcus serum has been employed sub- 
cutaneously in a dose of 3 to 5 cc. Good results have been reported, 
but its action does not seem to be sufficiently certain to allow it to 
replace other methods. On the other hand, a bacterin prepared 
from the microorganism which is responsible for the corneal infection, 
by which an active immunization is created, has in a number of 
reported instances been of signal service, but even such a bacterin 
must not be used to the exclusion of the other remedies which have 
been described. In place of antipneumococcus serum, antidiph- 
theritic serum has been employed with success in the treatment of 
severe corneal ulceration. 

Sequelae of Corneal Ulceration. 

After healing of a corneal ulcer the cicatrix consists of a more or 
less dense white spot in the cornea (macula) . If these scars are thick 
and white (leukomas) , they are irremediable by local medication and 
require surgical interference for relief. If, however, they are diffuse 
(nebulas), much good will follow systematic massage of the cornea, 
aided by the introduction of a small particle of yellow oxide of 
mercury salve The massage is performed as follows: A piece of 
the salve the size of a split pea is introduced beneath the upper lid; 
upon the closed lid a finger is placed, and regular motions made 
through the lid over the surface of the cornea— namely, vertical, 
lateral, and radial motions, the seance being completed by circular 
movements. The whole should last from one to three minutes. 
Alleman claimed excellent results in dissipating corneal opacities 
by the use of electricity by connecting a suitably prepared electrode 
with a battery, the cathode being placed directly on the previously 
anesthetized cornea and the anode on the cheek. Subconjunctival 
injections of physiological salt solution, placed near the corneal 
margin, have some power in causing absorption of corneal nebula. 
The internal administration of thiosinamin has been recommended; 
the author has never observed encouraging results from the use of 
this remedy or of fibrolysin (15 per cent, solution given by injection). 



LARYNGITIS 861 

Dionin is of service in corneal infiltration of recent origin. The 
destruction of a cicatrix following the perforation of a severe corneal 
ulcer, due to its failure to resist the effect of intra-ocular pressure 
constitutes a staphyloma. Pressure bandages, myotics and, in suit- 
able cases, iridectomy may be of avail in saving sight; often enuclea- 
tion is required. 

LACRIMAL ABSCESS. 

Lacrimal abscess results from suppuration in a chronically dis- 
tended lacrimal sac owing to the presence of obstruction in the 
nasal duct, and exists as a swelling under the skin at the inner can- 
thus, pressure upon the surface causing an escape of pus through 
the canaliculi. The treatment is practically confined to surgical 
interference— that is, division of the canaliculi and washing out the 
distended sac with antiseptic fluids, and removing the obstruction 
in the nasal duct by the use of probes as soon as the inflammatory 
symptoms have subsided; or, if the skin over the seat of the abscess 
is thinned and rupture is threatened, by free incision downward and 
outward. In purulent discharge from the lacrimo-nasal duct solu- 
tions of formaldehyde (1 : 6000), nitrate of silver (1:500), or protargol 
or argyrol (2 to 5:100), injected through the passage, favorably 
modify the unhealthy secretion but great care must be taken lest 
the silver salts penetrate through a false passage into the surround- 
ing connective tissue and form an indelible stain. For this reason 
many surgeons deprecate the use of these remedies in this regard. 
Much comfort will ensue from the use of hot compresses over the 
inflamed area. Excision of the lacrimal sac is the best surgical 
procedure for chronic dacryocystitis; West's operation, or a window 
resection of the nasal duct through which the secretion and tears 
drain into the nose has been highly commended by some surgeons. 

LARYNGITIS (ACUTE). 

The treatment of acute laryngitis is identical in many respects 
with that directed against acute inflammatory processes elsewhere. 
It may be divided into local, external, and internal methods. The 
condition of the larynx when acutely inflamed is that of intense 
hyperemia and irritation, and the object of the physician must be 
to allay this irritability. This is best accomplished by the use of 
compound tincture of benzoin, which is placed in boiling-hot water 
(1 ounce to the pint [30.0:480 cc]), and the steam inhaled as it 
rises from a pitcher or as it passes out of the nozzle of a deep 
coffee-pot. Another method consists in the use of a can or 
wide-mouthed bottle arranged with one long and one short tube 
like a Wolff bottle, the air being drawn into the larynx through 
the short tube, after bubbling through the medicated water. (See 
Inhalations, Part III.) This inhalation should be resorted to six 
or eight times a day, but the patient must not go out of doors or into 



862 DISEASES 

a cold room, as the steam relaxes the parts involved and renders 
them more susceptible to cold. Sometimes advantage is gained by 
adding to this inhalation 1 grain (0.06) of menthol. If the patient 
is unable to remain in an equable temperature, then the steam 
inhaler should be supplanted by a nebulizer, in which should be 
placed the following mixture: 

I$— Mentholis gr. iij (0.2) 

Alboleni fgj (30.0).— M. 

S. — Use as a vapor. 

The patient is directed to inhale this vapor gently, which because of 
its lightness readily passes deeply into the air-passages, and has the 
effects of soothing rather than irritating them as does the spray 
from an atomizer. 

Rarely in the very acute stages of laryngitis should a water spray 
be employed to wash the laryngeal mucous membrane, as it is apt 
to increase the irritation. If any aqueous spray is used, as may be 
neccessary when the irritation has resulted from the inhalation of 
dust, it may be made up as follows: 

1$ — Sodii chloridi gr. xv (1.0) 

Acidi borici . gr. x (0.6) 

Sodii boratis gr. x (0.6) 

Aquserosae f giij (90.0) — M. 

S. — Use as a spray. 

The external treatment, if the inflammation is exceedingly severe 
and the patient can be confined to bed, consists in the application 
a mustard plaster over the larynx, or instead a cold compress should 
be applied and kept in place with a long stocking tied around the 
neck. This soon becomes a warm compress by the heat of the body 
and may be kept in place all night. The cold followed by heat 
produces excellent results. A mustard foot-bath and a warm drink 
on going to bed are useful. 

The internal treatment should consist in opening the bowels with 
calomel and a saline purgative if constipation is present, and in the 
administration of full doses of aconite and bromide of sodium or 
strontium, as follows: 

]$ — Tincturse aconiti TUxl vel lxxx (2.6-5.3) 

Sodii bromidi 3ij (8.0) 

Syrupi lactucarii f5J (30.0) 

Aquge destillatse q. s. ad fgiij (90.0). — M. 

S. — Dessertspoonful (8.0) every hour until six or eight doses have been taken. 

This prescription may in many cases be continued until convales- 
cence, as it checks cough, soothes the inflamed area, and allays 
arterial excitement. Often it is best to omit the aconite after the 
first few doses. In other cases good results follow the use of 2 or 3 
minims (0.12-0.2) of dilute nitric acid in water every half -hour or 



LEUCORRHCEA 863 

hour for six doses. This is useful in the early stages only. By the 
second day the patient should be directed to make a heavy applica- 
tion of tincture of iodine over the trachea and episternal notch, as 
high as is possible without the stain showing above the collar. In 
children and in some adults this is well substituted by oil of amber 
and sweet oil in the proportion of 1 to 3 parts rubbed on the skin. 

For the laryngeal stiffness following the inflammation preparations 
of coca are very useful given internally, and tonics to the general 
system are needed. In many cases the prescription calling for 
ammonium chloride in the article on Bronchitis is useful. 

Abrams asserts that freezing the skin over the insertion of the 
internal laryngeal nerve, near the thyrohyoid space, where it enters 
the larynx, is a very useful curative measure. This may be repeated 
several times if necessary. The writer has never used this measure. 

LEUCORRHEA. 

This is a condition— vulgarly known as the " whites"— consisting 
in a hypersecretion from those glands which pour out their contents 
into the vagina or the cervical canal of the uterus, or even into the 
cavity of this organ. It is a state dependent upon many causes for 
its existence, the chief of which is laceration of the cervix uteri in 
child-bearing women. The character of the discharge varies with 
almost every case. In some instances it is thick and tenacious, and 
in others so liquid as to trickle down the limbs and soil the clothing. 
In most of the latter cases catarrh of the Fallopian tubes or ovarian 
irritation and tenderness are present. When the secretion is very 
thick and tenacious it generally arises from the cervical canal, while 
that from disorder of the vaginal wall alone, independent of other 
morbid conditions, may be either thick or thin. 

The treatment of these forms of leucorrhea may be divided into 
two parts— one, that directed to the remedying of the morbid process 
through the use of drugs by the mouth; the other, by their employ- 
ment locally. In obstinate cases the repair of a lacerated cervix or 
the curettement of the uterus is necessary. 

It is needless to state that in that form dependent upon excessive 
lactation or other exhausting manner of life tonics of an active 
character are needed. As a general rule, anemia will be present, 
and the following pill will be found of service: 

^ — Arseni trioxidi gr. J (0.015) 

Ferri reducti . . . gr. v (0.3) 

Quininse sulphatis gr. xx (1.3). — M. 

Fiant pilulse, No. xx. 

S. — One pill three times a day, after meals, for an adult. 1 

Or, 

I$— Tincturse cinchonse composite f gij (60.0) 

Tincturse gentianae composite . q. s. ad f §iv (120.0). — M. 

S. — Dessertspoonful (8.0) three times a day, after meals. 

1 In this prescription the small amount of iron given will probably be noted but this 
is done advisedly, as iron does as much good to the blood in small as in large amounts 
under most circumstances. (See Iron.) 



864 DISEASES 

The following pill may also be employed: 

1$ — Hydrargyri chloridi corrosivi gr. \ (0.03) 

Fiant pilulse, No. xx. 
S. — One pill three times a day after meals, or a tablet triturate may be used instead 
of a pill. 

When any preparation of iron is used care must be taken that the 
bowels are kept active and that the stomach is not disordered. Asso- 
ciated with the use of these internal remedies should be a moderate 
amount of exercise and the avoidance of late hours and rich foods. 

The local applications which are of value in these states consist 
in counterirritation and vaginal injections or painting with proper 
fluids the mucous membrane of the parts from which the discharge 
comes. In the leucorrhea dependent upon irritation of the ovaries 
associated with catarrh of the Fallopian tubes the use of small blis- 
ters formed by the employment of cantharidal collodion or a can- 
tharidal plaster over the groin on either side is often accompanied by 
good results. At the same time the vaginal surfaces surrounding 
the cervix uteri may be painted with a mixture of iodine, phenol, 
and chloral, such as was used by Goodell, as follows: 

R — Iodi resublimata 5iv (16.0) 

Phenolis, 

Chlorali hydrati aa §j (30.0) 

Rub the iodine and chloral in a glass mortar into a powder and add the phenol. 
S. — Formula. To be used by the physician only. 

The remaining treatment of watery leucorrhea consists in the 
use of astringent injections. A cheap astringent injection is made 
by adding 1 ounce (30.0) of powdered white-oak bark to each pint 
(480 cc) of hot water, or tannic acid and glycerin in the propor- 
tion of 1 ounce to 2 quarts (30.0:1920) of warm water. Ringer 
recommends the following: 

1$ — Sodii bicarbonatis 5J (4.0) 

Tincturse belladonna? folio rum f 5ij (8.0) 

Aquae Oj (480 cc).— M. 

S. — Use as a vaginal wash. 

Where the discharge is fetid a solution of permanganate of potas- 
sium should be used as an injection in the strength of J dram to 1 
pint (2.0:480 cc) of water. 

In purulent vaginitis, specific or otherwise, the following injection 
is serviceable: 

R— Creolini f3ss vel f 3ij (2.0-8.0) 

Fluidextracti hydrastis . . . . . . f 5iiss (10.0) 

Aqua3 fgviij (240.0).— M. 

S. — Add 2 tablespoonfuls to a pint (30.0:480 cc) of hot water, shake thoroughly 
and use as an injection, 



LUMBAGO 865 

A very useful astringent injection is: 

!ty — Zinci sulphatis 5J (4.0) 

Alumini sulphatis 5j (4.0) 

Glycerini f5vj (180.0).— M. 

S. — A tablespoonful (16.0) to each quart (1 liter) of water. 

The injected fluid should always be as hot as the patient can bear, 
as tepid injections are harmful. 

Sometimes a tampon thoroughly saturated with a powder of iodo- 
form and tannic acid, equal parts, and packed around a discharging 
uterine cervix is of service. 

When using vaginal injections it is important to remember that 
they should be in large quantities. Nothing is more antagonistic 
to true asepsis than the manner in which these applications are 
often made. Often a pint of the solution is placed in a basin over 
which the woman squats, and by means of a syringe forces the liquid 
into the vagina as fast as it run out, thereby filling the syringe joints 
with the dissolved secretions, and returning to the vagina as soon 
as they flow away the impurities which have left it. The only 
proper way to give such an injection is to use a fountain syringe or 
to have the solution in one basin, to the extent of 1 gallon (4 liters) , 
while the patient squats over a second basin, into which the impure 
liquid may run. 

LID ABSCESSES. 

Lid abscesses are seen more frequently in children than adults, 
as the result of injury, the sequel of acute illness (epidemic influenza, 
pulmonary catarrhs, fever, etc.), or from local infection; under the 
latter circumstance they may assume a gangrenous type. The 
treatment is that for any form of abscess— poultices, preferably in 
the form of hot compresses, early incisions, antiseptic solutions, and 
tonics. 

LUMBAGO. 

This is a form of myalgia or muscular rheumatism of the muscles 
of the loins and small of the back, and is frequently the result of 
lifting heavy weights, or it is due to other strains. In many cases 
acupuncture is very useful, particularly if the trouble is bilateral. 
(See Part III.) Sometimes after the employment of this measure 
the patient can straighten the back at once and retain that position. 
In other instances antipyrine or acetanilid, in 5- to 10-grain (0.3-0.6) 
doses of the former and 4- to 8-grain (0.25-0.5) doses of the latter 
are of service, and iodide of potassium and salicylic acid are not to 
be forgotten if the condition of the patient does not rapidly improve. 
Aspirin, phenacetin, and phenyl salicylate (salol) are also useful, 
combined or alone. A large hot poultice applied to the back is 
often efficacious in obstinate cases. Sometimes the use of a hot 
foot-bath and a Dover's powder on going to bed will produce a cure, 
and ironing the back with an ordinary hot laundry iron at a proper 
55 



866 DISEASES 

heat, a piece of newspaper or cloth being placed over the skin under 
the iron, is very efficient. Counterirritation in the shape of a blister, 
a mustard plaster, or capsicum draft will often give relief. No diag- 
nosis of lumbago should be made until sacro-iliac strain has been 
excluded. Strapping often relieves sacro-iliac pain. 

Where these measures fail, an ether or chloride of ethyl spray 
may be played on the center of the painful area until the skin is 
greatly blanched. 

MALARIAL FEVER. 

(See Intermittent and Remittent Fevers and Pernicious 
Malarial Fever.) 

MANIA (ACUTE). 

Space is wanting to consider the thorough and complete treat- 
ment of mania as it comes to the neurologist. All that can be 
mentioned here are temporary measures suitable for cases which are 
brief in their course. 

For the rapid quieting of the patient hyoscine hydrobromide may 
be used hypodermically in the dose of ^ grain (0.0012). In other 
instances, if the kidneys and heart are healthy, full doses of chloral 
may be used; and if an active preparation of cannabis can be had, 
at least 1 grain (0.06) of the solid extract or J to 1 dram (2.0-4.0) 
of the tincture should be employed. Cannabis will be found much 
more serviceable if 60 grains (4.0) of one of the bromides be combined 
with it. 

When a patient suffering from mania is so violent that nothing 
can be done with him, he should be held, and an emetic dose of yy 
grain (0.005) of apomorphine be given hypodermically to produce 
vomiting and so relax the muscular system; or he may be tied or 
anesthetized sufficiently to enable the physician to administer proper 
remedies. Sometimes full doses of morphine are needful, or a cold 
douche to the head while the body is in a tub of hot water is of 
service. In others a hot cabinet bath or Russian bath is a valuable 
sedative, and, if possible, should be used in preference to drugs. 
(See Heat.) 

MELANCHOLIA. 

This is not the place for the discussion of melancholia of so severe 
a form as to amount to insanity, since the treatment of this latter 
state is very various and largely depends upon the skill of alienists. 

There is one form of melancholia, however, which may often be 
quickly relieved by a simple measure. It is that dependent upon 
the condition of the system in which oxaluria is present. Whenever 
an individual complains of melancholia the urine should be exam- 
ined, and if an excess of oxalate crystals are found, the strong, 
freshly made nitrohydrochloric acid should be given in the dose of 5 



MIGRAINE 867 

minims (0.3) after each meal in a half-tumblerful or more of water. 
In order to guard against errors in diagnosis it is well to remember 
that pears, tomatoes, rhubarb, and cabbage all cause oxalates to 
appear in the urine for a short period after their ingestion. 

MENINGITIS (ACUTE). 

In a large proportion of cases the development of meningitis is 
secondary to some other state of disease, as, for example, otitis 
media or croupous pneumonia. Under these conditions the treat- 
ment must be governed by the exciting cause. 

When meningitis is due to tuberculosis we can do nothing save to 
give relief from pain, if it is present, by sedatives and lumbar punct- 
ure. When it is due to an infection of the meninges by the pneu- 
mococcus or typhoid bacillus this is also true. If it is caused by 
the diplococcus intracellularis of Weichselbaum, that is, if it be true 
cerebrospinal meningitis, the only remedy of any real value is the 
antimeningitis serum, which is to be injected into the spinal canal 
after an equal quantity of cerebrospinal fluid has been withdrawn. 
(See Antitoxin.) It is to be recalled that this serum acts as a bac- 
teriolytic or bactericidal agent rather than as an antitoxin. (See 
Hexamathylenamine.) In the way of palliative measures the following 
measures may be resorted to. 

During the first acute stage an ice-bag should be applied to the 
head both for its local influence and its antipyretic effect, and leeches 
may be put at the nape of the neck with advantage. As the disease 
advances and the nervous disorders of the affection become marked, 
sedatives are required to ally the twitchings, muscular spasms, or 
convulsions, and for this purpose no drugs excel chloral and the 
bromides. The doses to be used vary with the violence of the 
symptoms, but it may be stated that the chloral should rarely, if 
ever, be used in doses above 10 grains (0.6), and the bromides given 
in the dose of from 20 to 40 grains (1.3-2.6). If coma comes on, a 
large blister may be applied to the nape of the neck. 

Quinine has been recommended in meningitis, but it is absolutely 
contraindicated, as it predisposes to meningeal congestion. 

The treatment of the advanced stage of meningitis must be neces- 
sarily supportive. Alcohol should be given with the food if weakness 
is present, and a very simple or milk diet insisted upon. 

If symptoms of cerebral pressure are marked, lumbar puncture 
should be performed, the technique of which is described under 
Lumbar Puncture and Procaine. Of course, no drug is injected. 
In many cases the relief is only temporary, but in a few it is perma- 
nent. 

MIGRAINE. 

Migraine is a form of head pain usually limited to one side of the 
head— hemicrania. It is often characterized by the presence of 



868 DISEASES 

severe boring pain in the eyeball or over the brow on one side. Asso- 
ciated with or preceding this pain there may be some dimness of 
vision or even a true transient amblyopia. The exact pathology is 
not clear, and so our treatment of it is perforce largely empirical. 
As soon as the first warning symptom develops a bottle of citrate of 
magnesium should be taken, even if constipation is not present. 
Before the introduction of the coal-tar products as pain-relievers, 
the best treatment of the attack of pain consisted in ordering the 
patient to bed and giving him 15 to 30 drops (1.0-2.0) of tincture of 
gelsemium, with \ to \ grain (0.015-0.03) of extract of cannabis 
every two hours. If the heart is feeble, the fact that gelsemium is 
a cardiac depressant must not be forgotten. So far as the other 
measures for relief of the individual attack of pain are concerned, 
reference should be made to the article on Neuralgia. For the cure 
of the condition which results in the attack, the endeavor should 
be to keep the liver active, since the failure of this organ to destroy 
the poisons which cause an attack, and its failure to prevent fermen- 
tation in the bowel by the proper secretion of bile, is supposed to be 
the chief cause of the disorder. The use of sodium phosphate, taken 
in hot water every morning and on first arising, does good in many 
cases, particularly if the patient also takes some one of the salicylates 
several times a day, Rachford recommends: 

I^ — Sodii sulphatis gr. xxx (2.0) 

Sodii salicylates gr. x (0.6) 

Magnesii sulphatis gr. j (3.3) 

Lithii benzoatis gr. v (0.3) 

Tincturse nucis vomicae TTLiij (0.2) 

Aquse destillatae f5iv (120.0).— M. 

This mixture should be made up in large quantity and placed in 
a siphon by one of the concerns which charge soda-water, and from 
one-quarter to one-half glass of this water at ordinary temperature 
is to be taken every morning at least half an hour before breakfast, 
enough being used to ensure an adequate bowel movement during 
the forenoon. The ingredients meet several indications, for the 
sulphates of sodium and magnesium act as laxatives, the salicylate 
of sodium acts as a gastro-intestinal antiseptic and cholagogue, and 
the lithium benzoate aids in the elimination of effete materials repre- 
senting perverted metabolism. The small dose of nux vomica is 
introduced to mask the soapy taste of the mixture. A more agree- 
able mixture, put up at my suggestion in the form of an effervescent 
salt consists of 10 grains (0.65) of salicylate of strontium, 5 grains 
(0.3) of lithium benzoate, and 60 grains (4.0) of Rochelle salt. This 
dose should be repeated every half-hour until purging is free. Asso- 
ciated with this treatment, additional doses of salicylates may be 
used if needed, or benzoate of sodium may be given. The author 
prefers 10- to 20-grain doses of ammonium benzoate given in capsule. 
When evidences of intestinal fermentation are marked, the following 



MYALGIA 869 

pill may be used, devised by M. Allen Starr; it should be coated with 
phenyl salicylate to ensure its entrance into the bowel before it is 
dissolved : 

1$ — Sodii pheiiolsulphonatis gr. v (0.3) 

Potassii permanganatis gr. j (0.06) 

Beta-naphtolis gr. j (0.06) .— M. 

S. — One after meals and at night. 

An occasional free catharsis with blue mass is advisable in many 
of these cases. Usually 5 to 10 grains (0.3-0.6) once a week and 
followed by a saline is sufficient. It is essential that all causes of 
systemic and nervous worry be removed in these cases. Excessive 
sexual indulgence is often a cause of the attacks, and it must be 
interdicted. (See also articles on Headache and Neuralgia.) 

Some cases of migraine due to intranasal pressure are relieved by 
turbinectomy or straightening the nasal septum. 



MUSC^I VOLITANTES. 

Muscat volitantes is the name applied to the dark specks which 
patients frequently see floating across their fields of vision, espe- 
cially if the eyes are directed toward a bright sky or a white page. 
Usually they indicate no disease of the vitreous humor, and the 
ophthalmoscope fails to detect abnormal changes. They are attrib- 
uted to torpidity of the liver by the laity. Muscse volitantes may 
indicate eye-strain, and if the refraction is abnormal this should be 
corrected; a mild course of alteratives is often a useful adjuvant. 

MYALGIA. 

Soreness of the muscles either on pressure or on movement may 
be dependent upon a number of causes, such as strains, bruises, 
toxemia, or inflammation due to cold. Here, as in many other 
states, the treatment should be divided into the external and the 
internal methods. Of the internal remedies, the best are the salicy- 
lates or the iodide of potassium if rheumatism be the cause of the 
trouble. On the other hand, if a bruise or cold be the cause, the 
chloride of ammonium will be of service in 10- or 20-grain (0.6-1.3) 
doses given in a solution with fluidextracts of liquorice. (For pre- 
scription see Bronchitis.) Other remedies which may be tried with 
a good chance of success are full doses of an active fluidextract of 
cimicifuga (20 minims to 1 dram [1.3-4.0]) or the citrate or acetate 
of potassium in 20-grain (1.3) doses. 

The local medications are numerous, but only a few can be con- 
sidered as worthy of routine employment. The chief one is iodine, 
in the form of the pure ointment or the ointment diluted one-half 



870 DISEASES 

with lard if the skin is easily irritated. Another method is to employ 
a liniment, well rubbed into the skin, made up as follows: 

1$ — Tincturae belladonnae foliorum f 5iss (6.0) 

Tincturse aconiti f3vi (24.0) 

Tincturae opii f5ij (8.0) 

Linimenti saponis q. s. ad f$vj (180.0). — M. 

S. — Poison. To be used externally and only as a liniment. 

Sometimes chloroform liniment is singularly successful, and poul- 
tices applied as hot as can be borne and covered by oiled silk and 
cotton to retain the heat are often of great value. Massage or good 
rubbing is also a sine qua non for the successful treatment of this 
state. The use of high heat from electric lamps is very useful. 

NASAL CATARRH (ATROPHIC). 

In atrophic nasal catarrh the nostrils are roomy and the mucous 
membrane red and shiny. The formation of connective tissue has 
to a great degree obliterated the delicate serous glands, and the 
discharge of mucus, no longer diluted, forms inspissated crusts, 
which adhere to the mucous membrane of the septum and turbinated 
bones. Areas of ulcerated or abraded membrane are disclosed upon 
removal of these adherent crusts. 

The turbinated bones are gradually absorbed and the secreting 
surface thereby much reduced. Sometimes the wasting is so great 
that the posterior wall of the pharynx is clearly visible through the 
anterior nares. The inspissated secretion may form a cast of the 
nostril, and as fresh layers form underneath, the oldest part is raised 
until the whole interior of the nostril becomes a mass of decompo- 
sition, giving rise to an overpowering stench. This form of catarrh 
causes loss of the sense of smell, and the odor is not recognized by 
the patient himself. Ulceration or caries of the bony structure 
produces an odor even worse than the so-called ozena. The 'pharynx 
suffers from the general wasting, and presents a dry, varnished 
appearance called pharyngitis sicca, which is rather a symptom of 
nasal atrophy than a separate disease of the pharynx. 

The indications are the removal of all accumulations in the nose 
and nasopharynx and the healing of abraded or ulcerated surfaces. 
The early removal of dead bone is imperative, and what secreting 
surface remains must be stimulated as far as possible, to compensate, 
in a measure, for the glands that are hopelessly destroyed. In other 
words, efforts are directed toward producing a compensatory hyper- 
trophy of the glandular tissue that remains. Therefore with the use 
of antisepsis alteratives and local stimulation are combined. 

The nose should be thoroughly cleansed with an alkaline wash— 
Dobell's solution— warmed to increase its solvent power. To relieve 
the odor, we may increase the amount of phenol or substitute for it 
eucalyptol and thymol in the wash. Euthymol contains both of 
these and may be added to the wash. Its own pungent odor masks 



NASAL CATARRH 871 

somewhat the offensive odor. Permanganate of potassium may be 
used in weak solutions, but it is painful except when sensation is 
entirely lost. Peroxide of hydrogen is valuable used in an atomizer 
in the strength of 1 part to 10 or 1 to 20. After this has softened 
the crusts they should be dislodged by the further use of a warm 
alkaline spray, and after the cleansing is complete ichthyol, pure or 
diluted one-half with water or albolene, is applied by means of an 
applicator. Often a much weaker solution of ichthyol will do equally 
well. The patient may be given a salve of: 

3— Ichthyolis gr. xl (5.6) 

Mentholis gr. v (0.3) 

Petrolati albi 5j (30.0).— M. 

A piece of this is to be inserted into the nostril, after using a douche, 
each night. 

The solutions are best applied by means of an atomizer, or post- 
nasal syringe in the hands of the physician, or by snuffing from the 
hand or cup. 

The odor, if due to decomposition, is much decreased as soon as 
the passages are clear. The discharge must never be allowed to 
reaccumulate or much gain will be lost. 

Ulcerations require local stimulation by a strong solution of 
nitrate of silver or a superficial application of the flat surface of the 
galvano-cautery heated to dull redness. Necrosed bone should be 
removed, and it is often found detached in the nostril. 

Local stimulants should be judiciously combined with alteratives. 
Powders of nitrate of silver in starch, varying in strength from 1 to 
10 grains to 2\ drams (0.06-0.6:10.0) of the latter, may be blown 
into the nostrils by means of an insufflator. Cover gently the whole 
surface with a thin layer, and use it only of sufficient strength to be 
slightly felt. Nitrate of silver in solution, 1 to 10 grains to 1 fluid- 
ounce (0.06-0.6:30.0) gives better results at other times when applied 
to the mucous membrane. The physician must avoid over stimu- 
lating, and so exhausting the glands which it is wished to strengthen. 
The use of alteratives may alternate with the silver salt and iodide 
of potassium, and this may be done by using solutions of iodine 
and glycerin, as recommended for hypertrophic nasal catarrh. Inter- 
nally, we may employ iodide of potassium, to increase nasal secretions, 
and mucous-membrane stimulants and tonics. Attention should also 
be paid to the activity of the skin. (See Scarlet Red, Part II.) 

NASAL CATARRH (CHRONIC). 

Chronic nasal catarrh is essentially a disease of civilization, which 
may occur at any period of life, but more commonly develops from 
youth to early adult life. 

Although very prevalent among the upper classes, it is in the 
lower ranks that it most frequently reaches its later stages and its 



872 DISEASES 

worst forms. This does not result from lack of opportunity for 
treatment, but from the ignorance or indifference which this class 
show to diseases while there is no suffering and no interference with 
business. 

Hypertrophic nasal catarrh commonly has its origin in a neglected 
cold in the head or in a series of colds occurring in rapid succession, 
keeping the nose in a congested state until the erectile tissue covering 
the turbinated bones loses in a measure its power of contracting, and, 
decreasing the caliber of the nostrils, becomes a source of permanent 
obstruction to breathing. 

As the disease advances there is increased susceptibility to cold. 
Slight exposure produces a stuffy feeling in the nose. The nostrils 
may become completely occluded; usually, however, only one side 
at a time is obstructed at first, the obstruction showing a tendency 
to change sides. This change is most noticeable on turning in bed, 
the lower side usually stopping, and on changing the posture the 
obstruction is reversed, the clearing being accompanied by a crackling 
sensation. A slight tickling cough and tendency to clear the throat 
in the mornings may result from irritation of the pharynx or larynx. 

The first indications for treatment are the reduction of inflammation 
and restoration of the breathing-space. 

As the chief function of the nose is respiratory, the reestablishment 
of free nasal respiration, combined with the liberal use of antiseptic 
washes, will lessen the inflammation and irritation and produce a 
healthier state of the secretions. 

The writer places cleanliness at the head of the list of remedial 
measures. The alkaline wash recommended for Coryza, sprayed 
into the nose by a hand atomizer or gently snuffed from the palm of 
the hand or from a small cup, gives good results The hand warms 
the solution slightly, but when snuffed from a cup the solution should 
be artificially warmed. This wash may be used two or more times 
a day. 

The nasal douche should never be used where there is nasal obstruc- 
tion, on account of the risk of forcing the solution into the Eustachian 
tube and causing catarrh of the middle ear. 

In addition to the antiseptic wash where the mucous membrane is 
congested and irritable, the treatment recommended for coryza may 
be instituted for a few days with good results. A solution composed 
of equal parts of water of hamamelis and water or a dilute solution of 
hydrastis may be sprayed into the nose during the acute stage. 

A little later a spray of ferric alum, 5 grains to the ounce (0.3-30.0), 
may be applied carefully in an atomizer by the physician. It is not 
advisable to use alum in any considerable strength in the nose, as its 
continued use is liable to impair the sense of smell. 

The alterative and absorbent action of iodine makes it a valuable 
remedy for local application in very chronic nasal catarrh. It should 
be combined with glycerin in the strength of 6 or 8 grains to the ounce 



NEPHRITIS 873 

(0.4-0.5:30.0), with enough potassium iodide to make a solution. 
Apply this by means of a piece of absorbent cotton on the end of an 
applicator, along the floor of the nose, until it reaches the pharynx. 
It is needless to say that such an application as this should be made 
with the utmost gentleness. The cotton should project beyond the 
probe, and care should be taken to avoid bruising the tissues. 

After the irritation has subsided, as shown by the disappearance 
of the livid color and lessened sensibility, any remaining hypertrophied 
tissue should be removed by a competent rhinologist. 

NEPHRITIS (ACUTE). 

In the early stage of onset, for the reduction of inflammation cir- 
culatory depressants are to be resorted to, and aconite is generally 
most serviceable. The patient should be kept quietly in bed and 
given a milk diet, and hot compresses, cups or leeches used over the 
irritant loins if the urine is scanty. Blisters are not advisable, as the 
substances producing them may be absorbed and cause increased 
renal irritation. The restlessness will generally be quieted by the 
aconite; but if this fails, resort must be had to bromide of sodium or 
small doses of opium, which must be given cautiously, as these drugs 
are not readily eliminated when the kidneys are diseased. Cannabis 
is thought to be of great service if bloody urine is present, but chloral 
is generally too irritating to the kidney to justify its employment. 
The appearance of large amounts of blood in the urine at about the 
fifth day of the illness is an indication, according to Sydney Ringer, 
for the use of drop doses of tincture of cantharides, given every few 
hours. Personally the author would be afraid to use this method 
of treatment. 

Should the urine be scanty and of high specific gravity, and con- 
stipation be present, some calomel, followed by a purgative dose 
(§ an ounce [16.0]) of sulphate of magnesium should be used to aid 
in the elimination of impurities by the bowel. Warm mucilaginous 
drinks, as flaxseed tea, are of service, and the use of sweet spirit of 
nitre with moderate use of pure water should be resorted to to 
increase urinary flow and promote the action of the skin. It is not 
to be forgotten, however, that an inflamed organ needs rest, and the 
too free use of water and diuretics may be distinctly harmful. 

If dropsy or symptoms of uremia (see Uremia, Part IV) come on, 
they may be relieved by the use of hydragogue purges, such as elate- 
rium, which is particularly useful in that it is supposed to aid in the 
elimination of urea by the bowel. If vomiting is present, elaterium 
ought not to be used, as it irritates the stomach. Jaborandi or pilo- 
carpine may be used to sweat the patient at this time or in the earlier 
stages with advantage; J grain (0.008) of the hydrochloride should 
be given hypodermically, and repeated in fifteen minutes if no sweat 
appears; but it should never be forgotten that when the heart is 



874 DISEASES 

feeble or the patient very susceptible pilocarpine may produce serious 
collapse or pulmonary edema, and if this condition develops atropine 
should be used. This complication can sometimes be guarded against 
by the simultaneous use of strychnine in 2 \- grain (0.003) doses. Hot- 
air baths or hot packs are often useful to provoke sweat and are 
much safer than pilocarpine. (See Heat, Part III.) 

The treatment of the later stages consists in the use of stimulants 
to the kidneys to arouse them from the atony consequent upon the 
excitement of inflammation. To this end caffeine may be used in 
small amounts, or in their place the compound spirit of juniper or 
gin may be used as the case progresses. If the renal structure is 
persistently atonic, J to 1 minim (0.03-0.08) of the tincture of can- 
tharides at each dose may be used, and, as anemia is often a promi- 
nent symptom, tincture of the chloride of iron, which is both a 
diuretic and a tonic, should be resorted to. A meat-free diet should 
be rigidly enforced until few red cells are found in the urine. 

NEPHRITIS (CHRONIC). 

The treatment of chronic nephritis is a very different matter from 
that devoted to the cure of the acute form. It is quite impossible 
to cure the condition present, and we can only strive to improve 
the state of the kidneys and other organs by diet and the use of 
proper drugs. To arrest the disease all alcoholic drinks should 
be avoided as far as possible, and business cares and worries be cast 
aside. 

In both forms of chronic nephritis diet and mode of life are more 
important than the use of drugs although the latter are at times 
important adjuvants. In parenchymatous nephritis it is true that 
a milk diet fortified by cereals and vegetables in general is generally 
indicated, but it is important to bear in mind that a strict milk diet 
is unwise, because to obtain a sufficient number of heat units or 
calories in each twenty-four hours, a patient would have to ingest 
not less than four quarts of milk and thereby flood himself with 
fluid which his kidneys cannot get rid of because in this type of 
renal disease a lack of ability to excrete water is practically a con- 
stant state. Furthermore, the patient receives a relative excess of 
protein and a minimum of carbohydrate and cannot maintain a 
nutritional balance. As he cannot take four quarts of milk a day 
he starves and so uses his own tissues to support life, thereby becom- 
ing weaker and giving his eliminating organs the task of getting 
rid of the educts of his own tissue breakdown. In one of the earlier 
editions of this book the writer advanced the theory that when 
profuse albuminuria is present, a diet containing a fair amount of 
protein is needful to compensate for heavy loss of albumin and I 
note with interest that this view has recently been advanced by 
others. Moderate amounts of protein food are, therefore, often 



NEPHRITIS 875 

advantageous. The use of a skimmed milk diet is unwise because 
the patient is deprived of the nutritious cream to which there is 
no objection but value. The old idea that red meats are more 
harmful than white meats I have long taught to be untrue. Chronic 
parenchymatous nephritis cannot be treated by routine, but each 
case must be studied as to its needs. These needs are not based 
so much on the albumin and casts in the urine as upon the urine 
as* to its other organic and inorganic content and the state of the 
blood. During an acute exacerbation a skimmed milk diet for a 
few days may be wise, but as a general routine throughout the case, 
diet must be fitted to the patient's nutritive and eliminative needs. 
Even if the urine is not in full amount it may nevertheless contain 
almost the normal amount of solids. That is the water excretion 
may be the chief function impaired. In such an instance the mod- 
erate use of fluids is wise. The excretion of solids can be roughly 
estimated by Long's method of calculation of solids. This con- 
sists in taking the specific gravity of the twenty-four-hour urine 
and its quantity, which we will suppose is 1 liter. Multiply the 
last two figures of the specific gravity by 2.6. Thus if the specific 
gravity is 1.014, we will get as a result 36.4 grams of solids, whereas 
the normal output should be about 70 grams, but if the patient is 
at rest and on a limited diet, 36.4 grams is not unduly low. 

There is no justification in putting a patient upon a salt-free 
diet if there is no retention of chlorides. If there is retention the 
patient becomes dropsical because he retains salts to maintain the 
tonicity of his body fluids. The urine in such cases should have 
its chlorides estimated in twenty-four hours. During the next 
twenty hours about 5 grams of salt are added to the ordinary intake 
of food and the urine tested during the following twenty-four hours. 
Kidneys capable of secreting chlorides should get rid of this excess 
of salt in twenty-four hours. If little of it escapes then the intake 
of salt in food should be decreased because it is evident that this 
function of the kidneys is impaired. 

So, too, with meats, if a blood analysis reveals a non-protein 
nitrogen content of less than 40 milligrams per cent, it may be 
inferred that nitrogen retention is not in excess and protein food- 
stuffs are permitted in moderation. 

So far as drugs are concerned in parenchymatous nephritis it 
may be said that they have a limited value. The use of diuretics, 
even if they are efficient, which they often are not, is not wise if dropsy 
is due to salt retention. If the urine is scanty because a failing 
heart does not give the kidneys enough blood, digitalis is a useful 
indirect diuretic and if the arterial tension is high the nitrites are 
also useful. Liquor ammonii acetatis is a useful diuretic in some 
cases given in the dose of 2 to 4 drams (8.0-16.0) three or four times 
a day. Most of the good achieved from the use of Basham's mixture 
depends on the ammonium acetate, for the iron is in excess and the 



876 DISEASES 

anemia is toxic in origin and the iron does not remove its cause. 
Minute amounts of iron may do good for the associated anemia but 
it does not affect the kidneys. When the kidneys are able to excrete 
salts a useful drug is bitartrate of potassium, an ounce or more in 
a pint of water to be drunk as a beverage during the twenty-four 
hours. Often this dose also purges the patient. When dropsy is 
present blue mass (10 grains) with compound extract of colocynth 
(10 grains) may be used, or elaterium (J grain) or compound jalap 
powder in the dose of 40 grains (2.6). These hydragogue purges 
are, as a rule, contraindicated if there is salt retention, because 
the body is endeavoring to retain water to maintain the normal 
tonicity of its fluids. 

In interstitial nephritis albumin is scanty, the specific gravity 
low because of the polyuria and the low elimination of solids, and 
nocturnal polyuria is usually present, the kidneys apparently endeav- 
oring by extra endeavor at night to excrete solids that they could 
not get over the raised renal threshold in the diurnal period. The 
same dietetic rules hold here as in parenchymatous nephritis but 
the polyuria prevents dropsy which rarely appears unless the heart 
fails, that is the dropsy is cardiac not renal. A salt-free diet is there- 
fore not so necessary as a rule. Here again Long's method may be 
used to gain an idea of renal efficiency and examination of the blood 
for non-protein nitrogen is even more important in determining about 
the use of proteins. 

If a normal man is placed upon a moderate diet and allowed 
about 1700 cc of fluid in twenty-four hours, no fluid being allowed 
after 5 p.m. until 8 a.m., he will usually pass about 250 to 500 cc 
on arising, about 800 cc during the day and lose the balance in 
sweat and respiration. If he has interstitial nephritis, and this 
holds true in some cases of parenchymatous nephritis as well, he 
will pass a greater amount during the night or in the morning 
than normal. Further, in the normal man if the urine be passed 
at two-hour intervals during the day it will be found to vary quite 
considerably in specific gravity each time, because the kidneys adjust 
themselves to the needs of the body from time to time, whereas 
with chronic contracted kidneys the specific gravity is prone to be 
almost fixed and low, the kidneys having no elasticity as to function, 
that is the organs are lame, and care in the diet and caution as to 
exercise with its increased tissue waste is to be exercised. It is in 
this form of renal disease that the nitrites, say 1 grain of sodium 
nitrite four times a day, do the most good by lowering arterial 
tension and so saving the heart from excessive labor, but it is not 
to be forgotten that in many cases a high blood-pressure is essential 
to maintain the circulation through narrowed and tortuous vessels. 
In most of these cases avoidance of great mental activity, an easy 
life and the frequent use of electric cabinet baths will do more for 
the patient than any other measures. When these baths cannot 



NEURALGIA 877 

be obtained, the use of the hot pack may be resorted to. (See 
Heat, Part III.) So too, if there be no red cells in the urine indica- 
tive of renal irritation, Donovan's solution in the dose of 5 minims 
(0.3) three times a day is often useful. So too, residence in a 
warm climate, where there are not marked changes in the tempera- 
ture with high winds, is to be ordered so that the skin may be kept 
active and that the surface of the body be not chilled with resulting 
congestion of the internal organs. When there is a syphilitic history 
or a rheumatic or gouty diathesis the iodide of sodium in 15-grain 
(1.0) doses three times a day is often a valuable aid, the sodium 
salt being more easily dealt with by the kidneys than the salts of 
potassium and not harmful if retained, whereas the potassium may 
be in itself depressant when used for a long time. 

It is in this form of renal disease that nitroglycerin does the most 
good by lowering arterial tension and so saving the heart from exces- 
sive labor, but it is not to be forgotten that in many cases a high 
blood-pressure is essential to maintain the circulation through 
narrow and tortuous fibroid vessels. 

NEURALGIA. 

Like headache, neuralgia gives rise to much of the suffering expe- 
rienced by active persons who are not sick enough for bed. It affects 
people in every walk of life, and may be so severe as to incapacitate 
the most powerful man. 

The causes of neuralgia are very various, but they may be briefly 
stated to depend chiefly upon malnutrition and anemia, overwork, 
nervous excitement with consequent reaction, and upon reflex irri- 
tation from diseased organs, as in the case of supraorbital neuralgia 
from eye-strain or pelvic neuralgia from ovarian irritation or uterine 
inflammation. Nerves functionally diseased are always more or less 
active than normal; that is, hyper-excited, or depressed, above or 
below par. In both cases they must be brought back to their normal 
tone by appropriate remedies, and these consist in nervous excitants 
and nervous sedatives. To give a nerve already depressed the 
additional depression of a bromide, or a nerve excited the additional 
excitement of strychnine is harmful. 

From what has just been said, it becomes evident that the physi- 
cian must always determine the condition of the system of his patient 
and the causes of the neuralgia before administering remedies. 

The treatment of neuralgia, from its curative standpoint, may be 
divided into the use of tonics, laxatives, nutritives, and palliatives. 
(See Migraine.) 

Where neuralgia is associated with anemia no hope of permanent 
relief can be looked for unless iron and arsenic are used until the 
anemia is cured, and it is often necessary to combine with these 
drugs the use of cod-liver oil and bitter tonics. These are the cases, 



878 DISEASES 

too, in which nux vomica and strychnine raise the depressed nerves 
to increased activity, and so bring relief. How they do this is not 
known, but we know enough to recognize one or two important 
facts. Strychnine is certainly a nervous stimulant, and is also a 
stimulant to the anterior columns of the spinal cord. It probably 
also acts upon the trophic centers in the anterior cornua of the 
spinal cord, and by stimulating these centers increases the nutrition 
of the tributary nerve-fibers. 

It is needless to state that the neuralgias of syphilis and tubercu- 
losis are to be treated by the remedies usually directed to the relief 
of these affections, while at the same time the pain itself is carefully 
controlled by appropriate palliatives. 

When nervous exhaustion causes neuralgia, glycerophosphates and 
cacodylate of iron and sodium are useful remedies, particularly in 
those cases which are convalescing from acute fevers. 

Sometimes malarial poisoning produces a violent form of supra- 
orbital pain known as "brow ague," which is to be relieved, not by 
ordinary remedies, but by large doses of quinine. 

The relief of the states producing neuralgia having been spoken of, 
it yet remains to consider the measures to be adopted for the cure 
of an attack. Fortunately the recent advances of therapeutic study 
have placed in our hands a large list of drugs not apt to produce a 
habit after prolonged use, comparatively safe though active, and 
not of disagreeable taste or evil general effect. By these terms the 
writer refers to antipyrine, acetanilid, aspirin, and phenacetin, all 
of which possess wonderful power in the alleviation of pain dependent 
upon true nervous involvement. In order to avoid failure in the 
use of these drugs in the relief of headache, we must always remem- 
ber that their field of service is that of neuralgic pain, not other 
pains. Antipyrine is to be used in the dose of 5 to 10 grains (0.3- 
0.6) for ordinary neuralgia and more for the pain arising from the 
crises of locomotor ataxia, acetanilid in the dose of 3 to 8 grains 
(0.2-0.5) for the same purposes, and aspirin and phenacetin in the 
same amount as antipyrine. Aspirin in tablet or Capsule in the dose 
of 5 to 20 grains (0.3-1.3) is very efficacious. 

Upon these remedies combined with caffeine and the bromides 
according to circumstances, we now depend, and the following 
prescriptions will be found of service: 

1$ — Antipyrinae gr. xxx vel 3J (2.0-4.0) 

Caffeinae gr. xx (1.3).— M. 

Fiat in chartulas, No. x. 

S. — One every thirty minutes until relieved or six doses are taken. 

The following may be of use also : 

1$ — Antipyrinae gr. xxx vel 3j (2.0-4.0) 

Potassii bromidi . . . 5iij (12.0).— M. 

Fiat in chartulas, No. x. 
S, — One every thirty minutes until relieved, or until three doses have been taken. 



NEURALGIA 879 

Or, when the caffeine in the first prescription causes nervousness— 

1$ — Antipyrinse gr. xxx vel 3J (2.0-4.0) 

Caffeinae gr. x (0.6) 

Potassii bromidi 3iij (12.0).— M. 

Fiat in chartulas, No. x. 

S. — One as above. 

In any one of these prescriptions acetanilid or acetphenetidin may 
be substituted for antipyrine, and they should be used in preference 
to it if the heart is weak. Full doses of gelsemium may be used. 

A very effective remedy in some cases of neuralgia of the fifth 
nerve is croton chloral in from 5- to 20-grain (0.3-1.3) doses in pills 
or capsules of 5 grains (0.3) each. 

In some cases of anemic neuralgia of the head nitrite of amyl 
inhalations have proved useful, probably by reason of the cephalic 
flushing produced by this drug. 

In some cases repeated doses of castor oil, 1 to 2 ounces (30.0-60.0) 
a day, seem to exercise a very extraordinary influence in relieving 
neuralgic pain. Such cases probably depend upon deficient activity 
of the bowel with retained toxic material which gains access to the 
blood. (For Migraine, see article on that subject.) 

A very useful hypodermic injection in severe neuralgia is \ to J 
grain (0.007-0.015) of morphine, but the danger of beginning the 
morphine habit is to be remembered when treating chronic cases. 
Heroin in doses of T V grain is useful. Sometimes the surgeon may 
be called upon to do a neurectomy. 

A very large number of local applications have been used with 
success in obstinate neuralgias and other cases not so difficult of cure. 
Cocaine cannot be applied, as it does not penetrate the skin, but relief 
can sometimes be obtained by the local use of a menthol pencil 
rubbed over the spot if it be limited to area. Correction of eye-strain 
by glasses may relieve cephalic neuralgia. 

Where the nerve is very superficial it can often be treated by cold 
with great success. This is accomplished by freezing the parts with 
an ether, chloride of ethyl, or rhigolene spray, or by the application 
of a small piece of ice covered with salt to the part. 

Exceedingly severe neuralgia of the fifth nerve has been treated 
successfully by the injection of 90 per cent, alcohol with four grains 
of cocaine to the ounce, the quantity of the injection being from 15 
to 30 minims (1.0-2.0 grams). Injection of the superior branch 
is questionable because of possible trophic disorders in its distribu- 
tion, as in the eye. A straight hollow needle, large enough to carry 
a blunt-pointed stylet, but having a sharp point and marked off in 
centimeters, is employed. The sharp point of the needle is used 
to penetrate the skin. After the skin is penetrated, the stylet is 
pushed beyond the point so that the vessels will not be injured, and 
the combined needle and stylet is pushed in in such a way as to 
reach the nerve at its foramen. When the middle branch is to be 



880 ' DISEASES 

injected, the point of entrance is on the line of the posterior border 
of the ascending orbital process of the malar bone, which line is 
prolonged to the lower border of the zygoma. The needle is inserted 
half a centimeter posteriorly to this point and is directed vertically 
to the antero-posterior line, but inclines slightly upward in such 
direction that at the depth of the foramen rotundum it reaches the 
level of the inferior extremity of the nasal bones. In the ordinary 
individual the needle when introduced 5 centimeters meets the 
nerve as it emerges from the foramen rotundum. When the inferior 
branch is to be injected, the needle is inserted at the lower border 
of the zygoma, 2\ centimeters in front of the anterior root of the 
zygoma, which practically corresponds with the anterior wall of 
the external auditory canal. The needle is directed slightly upward 
to the base of the skull and a little backward, and at the depth 
of 4 centimeters reaches the nerve and its exit from the foramen. 
The injection is exceedingly painful, and should be done under 
nitrous oxide. The advantage of using this anesthetic, rather than 
ether or chloroform, is that the anesthesia is not so deep, and that 
some movement, or exclamation, of the patient reveals to the opera- 
tor when the nerve has been reached, thereby making him sure of 
his point of attack. It usually results in anesthesia in the distri- 
bution of the branch injected. (See Plate VI.) Where the pain 
has not been exceedingly intractable and it is hoped that more 
moderate measures will suffice a 60 per cent, alcohol solution may 
be used by injection into the upper branch as it makes its exit from 
the supraorbital foramen, or into the middle branch as it takes its 
exit from the infraorbital foramen. By manipulation the trochlear 
nerves at the inner angle of the orbit may be injected through the 
same puncture as that used to reach the supraorbital nerve. Here, 
again, at least procaine should be first introduced through the skin, 
but preferably nitrous oxide should be employed. 

The following statements by Cushing are worth reading, and I 
wish to call particular attention to the fifth paragraph: 

1. Deep extracranial injections of alcohol into the maxillary and 
mandibular nerve trunks near their foramina of exit from the skull 
have completely superseded peripheral neurectomies. 

2. In neuralgias limited to one of the two lower divisions and 
which may possibly not extend into the other trigeminal areas, 
alcohol injections represent unquestionably the treatment of choice. 

3. When the neuralgia has spread beyond its original area and 
come to involve that supplied by the adjacent division, a trigeminal 
neurectomy must be contemplated; but if no preceding deep injec- 
tion has been given, it may be useful not only in insuring the type 
of the neuralgia but in giving the patient some warning as to what 
the numbness resulting from the neurectomy may amount to. 

4. They are sometimes useful, furthermore, in determining in 
doubtful cases whether the syndrome is a true neuralgia of the tic 



< 




OBESITY 881 

douloureux type or one of the peculiar and rare pseudoneuralgias 
not amenable to relief either by injections or neurectomies. 

5. Even these extracranial injections are not entirely free from 
risk, and in no cases should they be purposefully pushed to the point 
of attempting an injection of the Gasserian sheath itself. 

6. With such perfect and permanent results as may be secured 
today by a trigeminal sensory root avulsion, the prolonged and 
repeated use of injections in refractory cases which involve more than 
one division should be deplored. 

NIPPLES (SORE). 

Whenever the nipples become sore, so that it is impossible for 
the mother to allow the child to nurse, a solution of cocaine of the 
strength of 4 grains to the ounce (0.25-30.0) should be applied to 
the part and washed off carefully just before the child sucks. Fol- 
lowing the nursing, a solution of boric acid, of the strength of 20 
grains to the ounce (1.3-30.0) or water or mucilage of acacia, may 
be used over the part, the nipple being first thoroughly dried. Where 
the fissures are deep and slow to heal the tip of a stick of silver 
nitrate may be applied to them with advantage. Some practitioners 
employ tincture of benzoin over the inflamed part, and glycerite of 
tannin is often of value. Cleanliness, dryness, and care of the breast 
previous to parturition do much toward preventing this condition. 
(See Balsam of Peru.) 

Sometimes it is necessary to use a breast-pump or nipple-shield 
before a cure can be effected. 

OBESITY. 

Whenever an excess of fat accumulates in the body, various 
discomforts, both mental and physical, arise, and in addition the 
normal functions of all the parts are so disturbed or interfered with 
that the continuance of health is often impossible. In many cases 
the deposition of fat about the heart or between its fibers results 
in serious symptoms; and breathlessness on exertion is produced by 
the obstruction which is offered to the free movements of the dia- 
phragm by masses of omental fat, aided by the fact that the great 
weight and bulk of the body requires severe muscular effort. It is 
worthy of note, also, that a layer of fat over the body increases the 
vascular surface very greatly, and in consequence gives the heart the 
labor of supplying a larger number of bloodvessels. 

In many families there is an inherited tendency to obesity, while 
in others only certain individuals are affected. These persons are 
fat because their bodies naturally tend to the deposit of obese 
materials, in the same way that the members of one family have 
large bones, while those of another have a small frame. The etio- 
logical causes of obesity, outside of those just named, are numerous, 
56 



882 DISEASES 

but the chief one is overindulgence in food, probably associated with 
some disorder of the thyroid, pituitary, and other glands of internal 
secretion. 

It is not out of place to state exactly what overindulgence in food 
means. Every individual is a law unto himself in regard to the 
amount of food which is ingested and consumed. One often sees 
large, powerful, wiry men, who eat little, stand beside others, not 
so powerful or large, who eat excessively, and who apparently do 
not suffer from indigestion in consequence. Neither of these groups 
becomes excessively fat, because one represents a grate which burns 
its fuel so that there is no waste, while the other resembles a grate 
in which there is always a residue of unburnt coal which is cast out 
with the ashes as effete matter. As different engines of the same 
build require varying amounts of coal, so do different men assimilate 
different amounts of food. No stated amount of food can be set 
down as a man's daily portion until his case is carefully studied, 
but it is important to remember that the quantity of food is gen- 
erally in direct ratio to the severity of the toil, and that a man who 
loiters about a club or "takes life easily" often eats more than a 
day laborer— of far richer foods, too— and wonders why he gets 
stout. In nearly every case of obesity not dependent upon gross 
disorder of nutrition overindulgence in food is the cause. To some 
this may seem absurd, and the patient will say that he eats just 
enough to keep him from feeling empty between meals; but this 
does not alter the case in the least. The proper amount of food for 
a man is not what his appetite or gastric viscus calls for, but what 
his system needs. To this further reference will be made when 
considering the diet for obesity, found below. 

The very presence of fat aids in the deposition of it, for, by acting 
as a non-conducting pad all over the body, it prevents the dissipa- 
tion of heat, and so decreases the combustion of those substances 
which, when not used for the manufacture of heat, are deposited as 
fat. Again, we find that obese persons often take alcohol with 
their food, thereby increasing the fat in their bodies; for, finding 
that they cannot digest all the substances which greediness makes 
them swallow, they take alcohol to stimulate their digestive appa- 
ratus to increased efforts and assimilation. Further than this, 
alcohol adds force to the body, and preserves the tissues by sub- 
stituting itself for food in the oxidizing processes. 

We find, therefore, that three great causes are active in producing 
corpulence in many cases— namely, heredity, overindulgence in food, 
and lack of exercise, which is one of the means by which overindul- 
gence is produced; i. e., less exercise, less food needed, but often 
more eaten. 

The treatment of corpulence rests solely upon the conditions 
named. In all instances the diet is the important point for the 
bestowal of care. Reference has already been made to the fact that 



OBESITY 883 

the needs of the system are the criterion by which should be deter- 
mined the amount of food necessary to each case, not the sensations 
in the stomach. The use of coca by the natives of South America 
enables them to withstand hunger and privation, not because it 
gives tissue to the body, but because it paralyzes the sensory nerves 
in the stomach and relieves the sensation of hollowness or weakness 
which we are accustomed to overcome in this country, in the absence 
of food, by tightening our belts. Every one who has undergone 
severe mental or physical labor and missed a regular meal will 
remember that about the usual hour for the meal his sensation of 
emptiness may amount to nausea and distress, but the hour once 
passed he feels as strong as before until by prolonged toil he so 
exhausts his powers that the system forces him to eat, not so much 
from hunger as from exhaustion. To understand this clearly, we 
must recollect that the system keeps its shares of force in the same 
way as a careful speculator keeps his shares of stock— namely, one 
part in active use for speculation, the other half for reserve in case 
of need. In health the stomach beings to "feel hungry" as soon 
as the speculative shares of force are nearly used, in order to 
cause the ingestion of more food and to preserve the " sinking 
fund" intact. It becomes evident, therefore, that the mere presence 
of hunger is purely a symptom, not an indication of the absolute 
necessity of food, for, if it were, the consumptive might be notorious 
for his appetite, instead of being noteworthy for his anorexia. 

The food of the patient suffering from obesity is to be cut down 
gradually, and the character of it arranged so that, though its bulk 
be great, its nutritive properties are small. Beef and other meats 
are concentrated foods containing much nourishment in a small 
bulk, while lettuce, spinach, cabbage, and nearly all vegetables, 
except roots or tubers, contain a large amount of fiber useless to 
the body. By the use of a carefully arranged vegetable diet in 
obesity we cut down the actual amount of food absorbed, and by its 
bulk keep the stomach so busy at sifting the nutritious from the 
non-nutritious materials that hunger is not felt, because another 
meal-time is reached almost before the food of the first is assimilated. 
We find, therefore, that the diet for the reduction of corpulence 
should consist chiefly of bulky vegetables, but not too exclusively 
of any one article or set of articles. Heretofore it has been thought 
that proteids (meats, eggs, etc.) should be used to take the place of 
all hydrocarbons or carbohydrates (fats, starches, and sugars), but 
this is not physiologically correct, as both forms of food are always 
needed for health, and it has been found that proteids may be con- 
verted into fats in the body. The following bill of fare will be 
found of service in the treatment of obesity. 

Breakfast: One or two cups of coffee or tea, without milk or 
sugar, but sweetened with a fraction of a grain of saccharin. Three 
ounces of toasted or ordinary white bread or 6 ounces of bran bread. 



884 DISEASES 

Enough butter may be used to make the bread palatable— not 
more than 1 ounce. Sliced raw tomatoes with vinegar or cooked 
tomatoes without any sugar or fats. This diet may be varied by 
the use of salted or fresh fish either at breakfast or at dinner. This 
fish must not be rich like salmon or sword-fish, but rather like perch 
or other small fish. 

Noon meal (dinner): One soup-plate of bouillon, consomme, 
Julienne, or other thin soup, or oyster broth, followed by one piece 
of the white meat of any form of fowl or a small bird. Sometimes 
a small piece, the size of one's hand, of rare beef or mutton, but no 
fat, may be allowed, and this should be accompanied by string-beans, 
celery (stewed or raw), spinach, kale, cabbage, beans, asparagus, 
leeks, and young onions. Following this, lettuce with vinegar and 
a little olive oil (to make a French dressing), a cup of black coffee 
or one of tea, and a little acid fruit, such as sour grapes, tamarinds, 
and sour oranges or lemons, may be taken, and followed by a cigar 
or cigarette. 

Supper should consist of one or two soft-boiled eggs, which may 
also be poached, but not fried, a few ounces of bran bread, some 
salad and fruit, and perhaps a glass or two of light, dry (not sweet) 
wine, if the patient is accustomed to its use. 

Before going to bed, to avoid discomfort from a sensation of 
hunger during the night, the patient may take a meal of panada, or 
he may soak Graham or bran crackers or biscuits in water and flavor 
the mass with salt and pepper. 

The reduction of diet is generally best accomplished slowly, and 
should be accompanied by measures devoted to the utilization of the 
fat present for the support of the body. Thus the patient should 
not be too heavily clad, either day or night, should resort to exercise, 
daily becoming more severe, and should not drink freely of water, 
unless sweating is established sufficiently freely to prevent the 
accumulation of liquid in vessels and tissues. 

Very often a cold bath will, by its dissipation of heat, cause 
destruction of fat, which will be burnt up in the body in the pro- 
duction of heat-units to maintain the temperature; and if the patient 
is not too anemic and stands this exposure to cold well, the bath 
should be repeated each day or a Turkish bath followed by a cold 
plunge used instead. 

The bowels should be kept active by the use of laxative fruits 
or purges, but if liquids taken in drink are not eliminated rapidly, 
saline purges are useful, since if the bloodvessels are engorged, the 
circulation in the capillaries is slow and a deposit of fat is apt to 
result. 

Where proper exercise is impossible the rest cure, with massage, 
electricity, passive exercise, iron and arsenic, and an absolute 
skimmed-milk diet, may be resorted to, particularly in those persons 
known as "fat anemics," who have not enough red corpuscles in 



PERICARDITIS 885 

their blood to carry sufficient oxygen to the tissues to complete 
oxidation. 

So far as medication is concerned, the value of the thyroid gland 
in some cases is not to be forgotten, particularly if any signs of 
hypothyroidism are present. (See Thyroid Gland, Part II.) 

OPHTHALMIA (SYMPATHETIC). 

This term is applied to an inflammation of the uveal tract (iris, 
ciliary body and choroid) of one eye, due to the effects of a similar 
inflammation of the other eye. 

The most usual lesions which produce this affection are wounds in 
the ciliary region, passing through "the danger zone/' about one- 
fourth of an inch wide, surrounding the cornea, beneath which lies 
the ciliary body, followed by an infective iridocyclitis; retained 
foreign bodies within the globe, which have created an iridocyclitis; 
perforating wounds or ulcers, with prolapse and incarceration of the 
iris, or scars involving the ciliary body. It occurs more commonly 
in children and young persons than in those of maturer years, but 
no age of life is exempt. The eye primarily thus injured is called 
the "exciting eye;" the fellow eye, to which the inflammation is 
transferred, is called the "sympathizing" eye. 

The affected eyes should be treated with atropine, as in all cases 
of iritis, unless there is rise of tension. Mercury internally, or by 
inunction, is usually advocated and should be tried, but the remedy 
which does the most good is salicylate of sodium in very large doses, 
as much as 1 grain (0.065 gm.) of this drug daily for each pound of 
body weight. As these large doses cannot always be borne, 60-100 
grains (3.9-6.5 gm.) per diem may be given. In place of the salicy- 
late, aspirin may be employed in very large doses. Arsphenamine 
and neoarsphenamine have been used with good effect. Other drugs 
which have been recommended are phenylcinchonic acid (40-60 
grains or 2.6-3.9 gm. daily) and benzosalin in full doses. Prophylaxis 
comprises the treatment of the eye originally injured, and preventive 
enucleation, if treatment is unavailing and sympathetic ophthalmia 
is threatened. 

PERICARDITIS. 

If the case be sthenic and is seen early, and the heart is over- 
acting, iive to ten leeches or several small fly blisters should be 
placed over the precordium. An ice-bag placed over the precordium 
not only relieves the pain, quiets the circulation, and reduces the 
temperature, but also acts favorably in modifying the severity of 
the inflammation. 

Where the case passes from the acute stage of inflammation to 
that in which effusion takes place, or if the patient is already 
depressed by illness, the treatment becomes supportive if the circu- 
latory system shows signs of failure. The friction-sounds of the 



886 DISEASES 

first stage are now lost, and the heart-sounds may be feeble or 
muffled by reason of the effusion present. Digitalis, alcohol, or 
caffeine may be used if the heart shows signs of failure; but when 
digitalis is used its influence should be carefully watched, since the 
employment of this drug produces a very full diastole or dilatation 
of the ventricles, and these are already cramped for space in which 
to dilate by reason of the exudate which has entered the pericardial 
sac. If the effusion is sufficient to endanger life, it should be tapped 
and aspirated very gradually. Often it is best to explore with a 
long trocar and cannula, attached to a syringe or aspirator, with a 
by-pass to one side. By this means the trocar can be withdrawn 
so that the heart will not be wounded, whereas the use of a needle 
with a sharp bevelled edge might do so. The instrument should 
be inserted gently, the operator feeling his way. Some authorities 
hold that the danger of wounding the heart is so great that it is best 
to make an incision. The best places for making the puncture are 
the fourth or fifth intercostal space, very close to the left edge of 
the sternum, or in the fifth right interspace, close to the sternum, but 
West advises the fifth and sixth interspace to the left of the nipple 
because the effusion pushes the heart upward and the lung to one 
side. If the tap is "dry" and the physical signs of effusion are 
positive, the posture of the patient should be changed and another 
trial made. Much aid can be obtained by the use of the x-rays in 
determining the point for tapping. Often a blister over the precor- 
dium is of service in aiding absorption. Should pus be present, free 
drainage must be established by means of an incision, and it may be 
necessary to excise the sternal end of the fifth rib on the left side. 

When an old pericarditis causes adhesions in such a manner as to 
seriously interfere with cardiac action the operation of cardiolysis 
is to be considered. 

PERITONITIS (ACUTE). 

The views of the best minds in the medical profession concerning 
the treatment of peritonitis have changed radically in the last few 
years, chiefly through the advances made in abdominal surgery and 
bacteriological research. These opportunities for study have shown 
that peritonitis never arises as a strictly primary condition, but is 
due in every case to the infection of the peritoneum by microorgan- 
isms, benign or malign, which originally are found in the intestines 
or other portions of the abdominal viscera. Even when peritonitis 
follows directly upon injury, the actual cause of the pathological 
process is the escape of microorganisms through the devitalized wall 
of the intestine, and the severity of the attacks depends in turn 
upon the vital resistance of the patient, the virulence of infection, 
and the rapidity with which a plastic exudate is thrown out to 
encapsulate the inflamed area. 

It is not possible in this article to discuss the facts now known in 



PERITONITIS 887 

regard to the etiology and pathology of acute peritonitis. Suffice it 
to state that the Bacillus coli communis found normally as a benign 
inhabitant of the intestine becomes at once, on entrance into the 
peritoneal cavity, malignant and capable of producing rapidly fatal 
peritonitis. Nor is actual rupture of the bowel or appendix vermi- 
formis necessary for this infection, since it has been shown that 
this germ rapidly migrates through the bowel-wall as soon as it 
becomes inflamed or congested in all its coats. Streptococci and 
staphylococci, finding access to this cavity, also produce violent 
inflammation. It has been found that the peritoneum will destroy 
many infecting germs if its vitality is not impaired, but if it is 
impaired, even a mild infection gives rise to severe inflammation. 

Having learned, then, that acute peritonitis is always secondary 
to some local cause or to some general infection, the first thing for 
the therapeutist to do is to determine what the provoking agent is, 
in order that his treatment may be directed against the cause rather 
than the effect. This cause is now known, in the great majority 
of cases, to be Appendicitis (which see), the inflammatory process 
being spread by infection from this source. In women it is not 
uncommonly due to more or less obscure pelvic disease; or, again, it 
may arise from abscess and other severe diseases of the liver, spleen, 
pancreas, or stomach. Finally, it should never be forgotten that 
intestinal obstruction and perforation are causes of peritonitis. 
The physician may rest assured that if he cannot find the provoking 
cause, it is his own fault, and he is not to decide that the case is 
purely idiopathic. 

Having found the cause, treatment is, of course, to be at once 
instituted, and is medical or surgical— more commonly the latter 
than the former — since nearly all the exciting causes of this disease 
are at most only palliated by medicinal treatment, while they can 
sometimes be removed by surgical interference Fortunately for 
those who can only obtain medicinal treatment, Nature does much 
to aid in producing a cure in many cases by limiting the disease 
through its localization by walls of lymph, so that many cases of 
peritonitis recover without active medicinal or surgical care. In 
the pelvis this localization of the process very often takes place. 

If the trouble arise in the appendix vermiformis, this condition 
may be treated in its early stages by the means suggested in the 
article on Appendicitis. In many cases requiring operation it is 
performed too late through the hesitancy of the patient, his friends, 
the physician, or even of the operator himself. 

In deciding the question, however, as to whether a case of peri- 
tonitis requires surgical interference, the physician at the present 
time is in an unfortunate position. There can be no doubt that 
there are many records in medicine which prove most conclusively 
that lives have been saved through operative interference which 
would have been undoubtedly lost had the surgeon not come to the 



888 DISEASES 

rescue. On the other hand, there are cases in which a fatal result 
has followed an operation, and in which the physician has bitterly 
reproached himself that he consented to surgical interference, for 
as he looked back over the case he perceived that the operation 
distinctly aided in causing the loss of life. At the present time each 
case must be decided upon its individual merits, and the physician 
or surgeon in giving advice to the family in regard to a well-devel- 
oped case of general peritonitis should always be careful to let them 
understand distinctly that the condition of the patient is most alarm- 
ing, and the chances of life poor whether the treatment be medical 
or surgical, since in many instances neither form of remedial measure 
can possibly produce good results. In other words, the relatives 
should clearly be made to understand that whether medicinal meas- 
ures or surgical procedures are resorted to, the patient has only a 
fighting chance. A localized peritonitis due to cholecystitis or ap- 
pendicitis should usually be operated upon, but if it is general a 
waiting policy is better. (See Murphy Drip and article in Appendi- 
citis). 

The patient should never be so narcotized by morphine as to have 
no pain on abdominal palpation or be unable to answer questions. 
On the other hand, it should be remembered that cases of peritonitis 
often bear large doses of opium without much effect. The dose should 
be pushed until the desired effect is obtained, and not be measured 
in grains. (For the proper use of opium, see Appendicitis.) 

An ice-bag or a turpentine stupe may be put over the area origi- 
nating the trouble. Should vomiting be a pressing symptom, it is 
best controlled by the use of 2 grains of acetanilid given every two 
or three hours on brandy and ice. Medication is best carried out 
by the hypodermic needle or the rectal injection. The thirst in many 
cases of peritonitis is excessive, and may be relieved by Murphy's 
method (see below) . Gastric lavage is often advantageous, particu- 
larly if there is vomiting. 

Post-operative, or septic, peritonitis, which for any reason is 
inoperable, is best treated by Murphy's method of saline irrigation 
by the rectum. This consists in placing and maintaining the patient 
in a semirecumbent position and then introducing slowly, drop by 
drop, normal salt solution at 102° F. The salt solution is placed 
in a Wolff bottle, which, in turn, is immersed in a water-bath, the 
temperature of which is carefully watched. Better still, the appa- 
ratus in Figs. 136 and 137 may be employed, the salt solution being 
frequently renewed. In other instances where a regular apparatus 
for this form of enteroclysis is not at hand, the scheme devised by 
Dr. S. Newman, of St. Louis, may be resorted to. (See Fig. 138.) 
By his plan an ordinary stand, such as is used in pharmaceutical or 
chemical laboratory, with brackets carrying two funnels, is employed. 
By means of a piece of rubber tubing attached to the upper funnel, 
which tubing can be compressed by a pinch-cock, the rapidity of 
flow from the upper funnel can be controlled. By means of a rubber 



PERITONITIS 



889 





GLASS "IT TUBE 
"T'TeR--".. 

■si?. - - STS-.tT *??°-;:2 

"^~""ri: 



1 ! GR )' I 



tube attached to the lower funnel the salt solution is conveyed to 

the rectum of the patient, and the fluid is heated by placing the 

bulb of an incandescent lamp in the lower funnel in such a way that 

it is in part submerged, and the fluid from the upper funnel falling 

upon it becomes heated. If the 

saline fluid in the lower funnel 

becomes too hot, the electric 

current can temporarily be turned 

off from the lamp. 

It is essential that the flow of 
saline solution through the cath- 
eter shall be controlled by means 
of some pinch-cock or other de- 
vice which will allow the fluid to 
dribble into the bowel, since if it 
flows too fast the bowel will be- 
come angry and expel it instead 
of absorbing it. Thirty drops to 
the minute is the usual maximum. 
Murphy advised the employ- 
ment of a rectal bulb or tip (see 
Fig. 139), provided with a 
shoulder, which enables it to be 
retained in the rectum with 
ease. This rectal bulb, has a 
A central canal through which a 




Fig. 136. — 'Coupling 
of glass to be put in 
rubber tubing so as to 
count the drop-rate, Fig. 137. — Proctoclysis apparatus, consisting of 
compressor to regulate syringe, large rubber tube and vaginal hard-rubber 
flow. (Meinecke.) tip. 



fountain 
or glass 



soft-rubber catheter is passed, which catheter carries the saline 
solution. In those instances in which the rectal bulb causes too 
much dilatation of the sphincter, and so induces irritation, the 
ordinary vaginal douche-tip, which is supplied with the commonly 
employed fountain syringe may be used in its stead. It is exceed- 



890 



DISEASES 



ingly important that the strength of the saline solution shall be 
slightly hypotonic (0.5 per cent.) instead of that of the tissues- 




Fig. 138. — Newman's apparatus for proctoclysis. 




Fig. 139.— Self-retaining tips on catheter, showing how adjustment can be accomplished 
by merely drawing catheter through to desired lengths. 

0.8 or 0.9. Stronger solutions will abstract liquid from the tissues 
instead of being absorbed. The vessel holding the fluid should not 



PLEUR1TIS, OR PLEURISY 891 

be elevated more than 6 or 7 inches above the anus, as a very slow 
delivery of the fluid is desirable. The irrigation is continued for 
several days in certain cases and the large amount of fluid which 
is absorbed by the bowel is remarkable. Some patients take as 
much as 16 pints in twenty-four hours. The theory of this method 
of treatment is that a reverse current of lymph in the peritoneal 
lymphatics takes place, so that instead of absorption occurring from 
the peritoneal surface, the openings of the lymphatics pour out fluid 
which escapes through the drainage-tube or tubes which are inserted 
through the abdominal wall. There is no doubt of the therapeutic 
efficiency of this method, which frequently saves otherwise hopeless 
cases, but there is doubt of the correctness of this explanation of 
its usefulness. The posture of patient aids in limiting the exudate 
to the pelvis. 

The tympanites, which may be a prominent symptom, may be 
relieved in some cases by the use of the rectal tube or by injec- 
tions into the bowel of milk of asafcetida or turpentine emulsion. 
(For formula, see Typhoid Fever.) 

PERITONITIS (CHRONIC). 

Chronic peritonitis is very apt to be circumscribed and to exist in 
connection with chronic appendicular trouble or in females in asso- 
ciation with diseases of the organs of generation. The most diffuse 
and curable form of the disease is that known as tuberculous peri- 
tonitis, in which cures have been safely reached through abdominal 
incision with or without drainage or the dusting in of iodoform. Of 
all forms of organic disease affecting the abdominal area and of a 
chronic type, none offer such favorable results to the physician and 
surgeon as does this, and operation should always be advised and 
urged upon the patient most strenuously, provided that type of 
the disease is present in which ascites and abdominal distention are 
marked. In that form characterized by matting of the coils of 
intestines and of the omentum, operation cannot give such good 
results. Care should be taken, however, to separate the subacute 
or chronic process termed tuberculous peritonitis, from the malignant 
and acute form called tuberculosis of the peritoneum, which is often 
only a manifestation of a general miliary infection. 

PLEURITIS, OR PLEURISY. 

When the pain from the pleurisy is excessive and the respiratory 
movements greatly increase the discomfort, strapping the chest-wall 
may be resorted to. This is done for the purpose of immobilizing 
that side of the chest. The straps should consist of adhesive plaster, 
two inches wide, and should be long enough to reach from the middle 
line of the vertebrae to the sternum or a little beyond its middle line. 
They should be applied tightly during expiration, slightly overlap- 



892 DISEASES 

ping one another at a right angle to the spine, and not in the line 
of the ribs (Fig. 140). Codeine, morphine or Dover's powder may 
be given. 

The old idea that pleurisy was usually due to cold rather than to 
an infecting microorganism led to the practice of enveloping the 
chest in poultices. These soil the clothing, speedily get cold, and 
become very uncomfortable. They have been supplanted almost 
entirely by the cotton jacket, which is much better. It consists 
of one or two thicknesses of carded cotton basted inside a thin under- 



% 



V\ 



£t. 



\ 



x 






Fig. 140. — Showing the overlapping of the adhesive strips in strapping the chest for 
painful pleurisy. The strips extend too far to the patient's right. Often only two or 
three of the lowest ones are sufficient. 

shirt, as fur is placed in a fur-lined coat. On the outside of the shirt 
oiled silk should be basted. By using this we envelop the chest in 
a warm poultice, because the heat of the body keeps the cotton 
at the proper temperature, while the oiled silk, by preventing evapo- 
ration of the moisture exhaled from the skin, soon causes the cotton 
to become moist as well as warm. Even the cotton jacket is losing 
its popularity, as the fever of the patient makes a hot jacket almost 
unbearable and it does little real good. Further, its removal is 
very apt to result in exposure to cold. The author never uses either 
of these dressings. (See Pneumonia.) 



PLEURITIS, OR PLEURISY 893 

When the second stage is reached and a pleural effusion, serous or 
purulent, has developed the physical signs consist in flatness on percus- 
sion over the lower portions of the chest, which area of flatness gener- 
ally varies with the change in the position of the patient from the erect 
to the recumbent position, unless the effusion is sacculated. Blow- 
ing or bronchial breathing at the apex of the lung, when this organ 
is compressed upward by the fluid beneath it, is often heard. If the 
effusion is on the right side, the apex beat of the heart is apt to be 
displaced to the left. If it is on the left side, there is obliteration of 
Traube's semilunar space, which is a spot at about the level of the 
sixth and seventh ribs anteriorly below the nipple, where there is 
usually a tympanitic note on percussion. 

If the effusion is sufficiently large to cause marked dyspnea or 
reaches to the third interspace anteriorly, it should be removed 
by aspiration. When the effusion is not causing dyspnea, or other 
evil symptoms by reason of pressure, that is, it is present in small 
amounts, the physician should allow sufficient time for recovery to 
occur; as, for example, a week or ten days, during which interval 
the system wilL in many cases remove the fluid by natural processes 
of absorption. If after this time has elapsed the quantity of fluid 
remains unchanged resort must be had to aspiration of the liquid. 
Purges ought never to be employed as they weaken the patient, 
and they are futile because the pleural surfaces are covered by a 
fibrinous exudate which prevents absorption. 

There is no danger in aspiration if it is properly performed. The 
best place to insert the needle is the sixth or seventh interspace in 
the middle axillary line. Care should be taken that the needle is 
aseptic; that the skin at the point of puncture is well cleansed; and 
that the exhaust-pump is working well. All the liquid should not 
be withdrawn at one sitting. Often the withdrawal of a portion of 
it will result in the natural absorption of the quantity which is 
allowed to remain in the chest. 

During this stage of effusion blisters have been largely used to 
aid absorption of the fluid which is present, but they are not of great 
service. When used they should be applied in the form known as 
flying blisters. (See Cantharides, Part II.) It is to be remembered 
that blisters are, as a rule, contraindicated in the case of children, 
because of the pain and irritation they produce. 

The time at which an effusion is to be removed, as already stated, 
depends chiefly upon how greatly its presence interferes with respi- 
ration. Even if the needle shows it to be purulent there is no imme- 
diate need of interference, but if septic symptoms or pressure symp- 
toms are urgent it must be removed. If the displacement of the 
heart is great we should first aspirate to relieve pressure and operate 
afterward. 

The method of removal of pus depends on the state of the patient 
who, if still acutely ill or very weak, should not be subjected to 



894 



DISEASES 



incision and drainage, with or without excision of a rib, until fit 
to stand a radical measure of relief. Pus does not usually form 
during a frank croupous pleuropneumonia but after the acute illness 
is over. It is a sequence not a coincident complication. 

If the decision is to postpone radical measures because of the 
general state of the patient the following plan may be followed, 
particularly if a diagnostic puncture has revealed the presence of 
the streptococcus. After local anesthesia is induced a cannula 7 
mm. in caliber is introduced in the seventh interspace posterior 
axillary line. Through this is passed a soft rubber 24 French catheter 
open at the end and with two lateral eyes. A large sterile syringe is 
attached and the pus withdrawn. Before the syringe is removed 
to empty it clamp the catheter to prevent entrance of air. Replace 




Fig. 141. — Arrangement of bottles for promoting lung expansion. 

the syringe and again withdraw pus and repeat until the cavity is 
empty. This interrupted method is preferable to rapid aspiration 
as it does not cause rapid expansion of the lung. The cavity is 
now washed out by injecting and withdrawing from 30 to 60 cc of 
Dakin's solution (see Antiseptics Part III) . The cavity is then filled 
with Dakin's solution which is allowed to remain in situ half an hour 
when it should be removed (see below). The tube should be kept 
clamped to prevent the entrance of air. The washing out should 
be performed several times in each twenty-four hours. When the 
fluid is found to be sterile the injections are cut down to twice a 
day and when the pus cavity holds only about 20 cc of the solution 
the tube is to be withdrawn and the wound allowed to heal. Always 
connect the syringe with the tube before removing the clamp to suck 
out or inject. 

The use of Dakin's solution, as pointed out in the article dealing 
with that fluid, is difficult in private practice although advantageous 
in hospitals. In its place chloramine-T, not dichloramine-T, may be 
employed in 0.5 to 1 per cent, watery solution. It is less toxic and 
does not so efficiently dissolve necrotic tissue as does Dakin's solu- 
tion but it is less irritating, When injected into the pleural cavity it 



PNEUMONIA 895 

need be changed but twice or thrice in twenty-four hours. Still 
another substitute more suitable for use by the general practitioner 
is called "Hy chlorite.'' (See Antisepsis, Part III). 

A radical objection to the removal of pus by aspiration and tube 
drainage is the fact that in many cases the pus contains large masses 
of fibrin resembling large clots which not only prevent free drainage 
but prevent recovery. If the fluid speedily recurs and septic symp- 
toms are present, or if the tapping manifestly fails to empty the 
cavity then incision, and, in adults at least, excision of a piece of rib 
is essential. The rule when empyema is present practically comes 
down to this : If the patient is acutely ill relieve pressure by tap- 
ping; if convalescent or able to stand operation operate. 

In order to cause proper expansion of the lung after convalescence 
is begun, chest exercises should be used (see Part III) and wash- 
bottles may be employed, as are shown in Fig. 141. 

PLEURODYNIA. 

This condition, being one of intercostal myalgia or neuralgia, 
should be treated according to the directions given under the head- 
ings of Neuralgia and Counterirritation. 

PNEUMONIA. 

Pneumonia is a term loosely applied to two different forms of 
disease— namely, that acute infectious process due to an infection by 
pneumococcus and called croupous pneumonia; and that form follow- 
ing, as a rule, some other disease which has exhausted the patient's 
strength and due in some cases to various forms of infection includ- 
ing the pneumococcus, namely catarrhal pneumonia. These two dis- 
tinct diseases have been confused by the common term pneumonia, 
and yet are very different conditions as to their pathology and 
treatment. 

There is, however, one factor in treatment common to both classes, 
whether they occur in children or adults, namely, plenty of fresh 
air. In well-appointed hospitals croupous pneumonia is treated out 
of doors, as in an open shed or on the roof, with the result that the 
mortality is far less than in the best ventilated wards. A few hours 
of fresh air will often produce remarkable changes in the patient's 
condition. The open-air plan is indicated in the croupous type. 
When bronchopneumonia is present it is of questionable value, par- 
ticularly in children or asthmatics. 

Croupous Pneumonia. 

The treatment can be divided into that devoted to the stage of 
onset, the stage of consolidation, and the stage of absorption of 
the exudate and convalescence; and it will be governed by the state 



896 DISEASES 

of the patient's pulse, the sounds of his heart, and his general con- 
dition as to strength, as well as the degree of respiratory embarrass- 
ment when it is present. There can be no routine treatment of 
croupous pneumonia as each case must be a law unto itself, and 
there is no such thing as the depletant treatment to be advocated on 
the one hand, nor the stimulant treatment to be lauded on the 
other. (For Antipneumococcic Serum see article on Antitoxin, 
Part III.) Further than this, it must be remembered that as crou- 
pous pneumonia is an acute infectious disease the patient may die, 
not from pulmonary consolidation nor cardiac distention, but from 
the malignancy of the infection. One man with an entire lung 
consolidated may have slight evidences of general infection or 
toxemia; another with a small area of lung involved may be over- 
whelmed by toxemia within a few hours. For this and other reasons 
all cases of croupous pneumonia may be divided into three groups 
—those that are doomed to death by the malignancy of the infection, 
those that are but slightly ill by reason of mild infection, and those 
which are between these two extremes of severity and need careful 
medical aid to accomplish recovery. The first class die, do what we 
will, the second class get well almost without help, the third need 
all the help possible to survive. It is to this last class that our 
treatment must be chiefly directed. 

It is of vital importance to remember that the patient does not 
need medicine simply because he has croupous pneumonia. 

The fact must not be lost sight of that croupous pneumonia is 
often a terminal infection superimposed upon nephritis or some 
other malady. The primary disease must, therefore, be considered 
in all plans of treatment. 

If severe pain in the chest is present, it is to be relieved by mod- 
erate doses of morphine or Dover's powder. 

In the majority of cases the physician is called after consolidation 
has occurred, and he must be a watchman all the time and a thera- 
peutist only when treatment is actually needed. Every patient 
who is suffering from pneumonia does not need active treatment. A 
certain number of cases get well without treatment, and do so sooner 
than if meddlesome therapeutics hinders them. The treatment usu- 
ally necessary is to combat fever if it becomes excessive, to support 
the heart if it seems feeble or engorged, to keep the kidneys in a 
state of active secretion, and to see that constipation is relieved. 

How anyone can see a hepatized lung and then think that those 
remnants of barbarism, cotton jackets and poultices on the chest, 
are going to do anything else than harm the patient I cannot under- 
stand. There is not a reader of this book who could tolerate a hot 
poultice all around his chest as long as it takes him to read this 
article. There would be a demand for more air because the poultice 
oppressed him, although he has two good lungs and a healthy heart. 
If a hepatized lung is the local lesion resulting from a general infec- 



PNEUMONIA 897 

tion, why should we poultice the chest in pneumonia any more than 
we would paint the abdominal wall with nitrate of silver to treat 
the intestinal ulcers in typhoid fever? 

In the treatment of the fever the physician should remember that 
it is not to be regarded as a dangerous symptom unless it rises to 
105° F. and remains at this point for some hours, for in a febrile 
disease running a short course fever is not only harmless, but there 
is also reason to believe that when present to a moderate degree 
it is actually beneficial. 1 When the fever persists at a point above 
105° F. it should be reduced by sponging with cool water, active 
friction being used at the same time. (See Cold in Part III.) There 
is absolutely no danger of the patient "taking cold," although this 
is generally doubted by the laity. If the fever has a tendency to 
be excessive or if the heart's action is tumultuous, an ice-bag may 
be placed over the heart. If it is desired to apply cold over a 
greater area of the chest than the precordium, cold compresses may 
be employed, but they possess the disadvantage of being wet appli- 
cations, do what we will to protect the bedding. The cold plunge 
bath is always badly borne in croupous pneumonia. (See Cold, in 
Part III.) 

The use of antipyretic drugs is not good practice. They tend to 
depress the heart, to relax the bloodvessels, and apparently render 
the patient more susceptible to his infection. 

For the support of the heart several circulatory stimulants may be 
employed. If the patient is an alcoholic and feeble, with lack of 
vitality and relaxation of his vessels, then alcohol in the form of a 
good whisky or brandy, given in water after food every three or four 
hours, in the dose of from half an ounce to an ounce is useful. Some- 
times more than this must be given, particularly if the patient has 
been accustomed to the use of the stimulant. In most cases none is 
needed. 

For the laboring heart with almost empty arteries no drug com- 
pares with digitalis; and if the skin is moist or the bloodvessels 
relaxed, so that the pulse is gaseous, then belladonna should be 
combined with it. The writer usually gives 10 minims (0.65) of a 
physiologically tested tincture of digitalis every eight hours, with 10 
minims (0.65) of the tincture of belladonna every four hours. (See 
Digitalis and Belladonna.) If necessary, both of these drugs may 
be given in larger dose, but usually these doses are sufficient. If 
the fever is very high, the digitalis will often have to be supplanted 
by alcoholic stimulants or strychnine for a few doses. The question 
as to whether the patient's pulse is of the proper strength is one of 
importance : very often the quiet pulse of a patient lying in bed will 
be taken by the anxious attendant as an evidence of true cardiac 
feebleness, when if the physician feels his own pulse he will be sur- 

1 See article on The Role of Fever in the Modification of Disease, in the Therapeutic 
Gazette for February, 1896. 

57 



898 DISEASES 

prised to find it no stronger than that of his patient. A feeble apex 
beat, a feeble second sound at the second right costal cartilage 
(aortic valve), and an accentuated second sound at the third left 
costal cartilage (pulmonary valve) will reveal the fact that active 
stimulation is needed, for the weak apex beat and the soft second 
(aortic) sound show that the heart is feeble and the arterial walls 
relaxed, and this means a low arterial pressure. Further, the accent- 
uated second sound on the left side indicates pulmonary congestion 
and a tendency to failure of the right side of the heart from obstruc- 
tion to the flow of blood in the lungs. 

One of the best means of determining upon the use of circulatory 
stimulants in pneumonia is the use of the sphygmomanometer. 
Gibson, in Edinburgh, and myself, in this country, have shown that 
danger arises when the pulse-rate per minute is equal to or above 
the systolic blood-pressure expressed in millimeters of Hg. Thus, 
if the pulse-rate be 90 and the pressure 140, all is well, but if the 
pulse-rate be 110 and the pressure 110, he is gravely ill and needs 
active cardiac and vascular stimulation. If the pressure in milli- 
meters of mercury falls below the pulse-rate, the condition is usually 
desperate. 

In many instances, however, the low pressure is not so much the 
result of weakness of the heart muscle but is present because the 
vessels are relaxed. In such a case the heart beats hard and fast 
in an effort to fill the vessels and becomes feeble more from fatigue 
than from toxemia. The heart does not need digitalis to make it 
work harder at this time but its strength will be conserved if by 
the use of atropine, strychnine, caffeine or camphor the blood-pressure 
can be raised by restoring vascular tone. An estimation of the 
diastolic pressure and the pulse-pressure will guide the physician 
better than an estimation of the systolic pressure. 

Should the action of the heart become labored, the jugular veins 
distended and pulsating, and the radial pulse weak, while the face is 
cyanotic, then free venesection (Part III) is to be practised. It will 
sometimes save an apparently desperate case. Digitalis in the 
presence of this condition is not rapid enough in its effects. 

Should collapse develop, strychnine (see Nux Vomica, Part II) 
should be given in full dose hypodermically ■£% to ■£$ grain (0.003- 
0.006), and with it, if the skin is moist or sweating, T ^$ grain of 
atropine (0.0006), and both these drugs should be repeated in an 
hour if needed. At the same time it is well to give 1 dram (4.0) 
of aromatic spirit of ammonia every two hours in cold water or 1 
dram (4.0) of spirit of ether in cold water every hour. Oxygen 
inhalations may be used at this time with benefit, particularly if 
cyanosis is marked. (See Oxygen and Shock.) 

Should crisis come on at this time, active supportant treatment, 
such as that just described, may be needed. Many patients die in 
crisis for the want of active stimulation. 



PNEUMONIA 899 

A point which I wish to emphasize is the error of writing prescrip- 
tions for a pneumonia patient and having them continued for days 
at a stretch. With the possible exception of belladonna, which is 
used to prevent vascular complications from suddenly arising, I have 
never seen any case of pneumonia which needed the same remedy, 
in the same dose, day after day. The skilled physician will fit his 
drug and his dose to the needs of his patient at each visit, for, like 
a captain of a ship, he cannot control the storm, but only handle 
his vessel. The captain of a ship who leaves the bridge with written 
orders to the helmsman at 10 o'clock in the morning and does not 
appear on deck again for twenty-four hours is courting disaster. 
The doctor who tells a nurse to use full doses of active remedies 
every few hours for the next twenty-four hours or for days is almost 
equally courting disaster. If the man needs stimulation he needs 
it actively in one or two doses. He rarely needs it again and again 
and again, unless he is in such a desperate state that the physician 
should stand by him to reach an accurate estimation of his condition 
from hour to hour. He may badly need help occasionally, but not all 
the time. A few good-sized doses of digitalis are often wise, but its 
persistent use is usually unwise. 

Nervous excitement with insomnia, if excessive, should be com- 
bated by small doses, \ to J grain (0.008-0.015), of morphine, given 
in the early evening by hypodermic injection, or, rarely, by 5- to 
10-grain (0.35-0.65) doses of barbital sodium. 

The secretion of the kidneys is best maintained by the use of 
some alkaline diuretic, such as sweet spirit of nitre and citrate of 
potassium, and if necessary a little gin may be given to support the 
heart and aid in maintaining renal activity. 

Expectorants in either type of pneumonia are never useful until 
the stage of resolution is well developed, if then. They cannot do 
good and they upset the stomach. There is nothing to spit up. 
Resolution takes place by the development of autolytic substances 
and we cannot hurry it. At best they only benefit bronchitis if it 
is present. 

Having detailed this treatment of the second stage, that for the 
third stage is to be considered. 

It must be remembered that in most individuals the process of 
repair is carried out best if the efforts of Nature are not meddled with. 

I wish to sound a note of warning against the use of iodides in 
cases of delayed resolution. The processes of Nature are best suited 
to the removal of the exudate in the vesicles of the lung. The iodides 
may hurry these unduly, and may in the general process cause an 
absorption of some old inflammatory mass which has walled off and 
rendered innocuous an old tuberculous deposit. In cases in which 
delayed resolution is present, and the physician is tempted to hurry 
it by the use of the iodide, he too often finds that the delay is not 
due to the remains of a frank pneumonia, but is the result of a ter- 



900 DISEASES 

minal or coincident infection by other organisms, and the officious 
interference of the physician when Nature is endeavoring to produce 
good results may be followed by disaster. Not rarely so-called de- 
layed resolution is really an empyema or an interlobar empyema. 

First and foremost for the relief of any associated bronchitis stands 
the chloride of ammonium, a drug which acts most happily in aiding 
in the loosening of the cough and secretions. Its only disadvantage 
is its salty taste, which in many cases renders it disagreeable to the 
patient, while its irritant properties may disorder the action of the 
stomach, although if this organ is depressed and atonic this drug 
often improves its condition. This drug may be given in compressed 
tablets, or, what is far better, in such a mixture as here follows: 

~fy — Ammonii chloridi 5ij (8.0) 

Fluidextracti glycyrrhizae f 3ij (8.0) 

Aquse destillatse f 5ij (90.0).— M. 

S. — Teaspoonful (4.0) in water every four hours during the day. 

If the cough be in excess of the expectoration— that is, if the cough 
often fails to bring up phlegm and is due to tickling or irritation— it 
may be relieved by the addition of a little morphine to this mixture, 
as follows: 

]} — Morphinae sulphatis gr. j vel gr. ij (0.06-0.12) 

Ammonii chloridi 3ij (8.0) 

Fluidextracti glycyrrhizae f 3iv (16.0) 

Aquae destillatse fgvj (180.0).— M. 

S. — Dessertspoonful (8.0) every four hours in water. 

If much more morphine than this is used, it will tend to stop secretion. 
When the chloride of ammonium fails to act favorably, the car- 
bonate may be called into use for its local and circulatory action, 
and, in addition, the bromide of ammonium may be employed to 
allay the cough if morphine cannot be used. The following pre- 
scription is valuable: 

R— Ammonii chloridi 3j (4.0) 

Ammonii bromidi 3J (4.0) 

Ammonii carbonatis 3J (4.0) 

Fluidextracti glycyrrhizae ' . f3iij (12.0) 

Aquse destillatse f5vj (180.0).— M. 

S. — Dessertspoonful (8.0) every four hours in water. 

In other cases heroin may be given in the dose of y 1 ^ grain (0.005) 
every eight hours to control excessive cough. 

(For other remedies for this stage see Bronchitis.) 

It must be borne in mind that the effect of expectorant drugs upon 
the pneumonic process itself is very slight, and that they are not to 
be given unless bronchial secretion is present in excess. 

Nutritious broths, milk, and, if necessary, predigested foods, 
should be given with even greater regularity than medicine would 
be given, from the beginning to the end of the attack, 



PRURITUS 901 

The problems in a given case are as follows: 

1. Has the patient croupous pneumonia? 

2. If so, what is his general state? 

3. Are the heart, kidneys, and vessels primarily diseased? 

4. Does he need any other treatment than rest in bed and good 
nursing? 

5. If so, what does he, that individual, need? 

6. Does he need stimulation, sedation, elimination? 

7. If he needs stimulation, does he require it right along, or only 
at the moment? When we eat we don't eat all the time, day after 
day, but only when we need food. 

8. As to all drugs follow Cromwell's motto, "Trust in God, but 
keep your powder dry." Don't give drugs all the time, but use 
remedies when needed fearlessly, and all the more advantageously 
because they have not been used before. 

Catarrhal Pneumonia. 

The main difference in the treatment of catarrhal pneumonia in 
distinction from the treatment of croupous pneumonia lies in the 
fact that first, last, and all the time the treatment is to be stimulant 
in its character if any treatment other than rest in bed is resorted 
to. Catarrhal pneumonia usually arises out of a severe bronchitis 
or is superimposed upon some exhausting disease which has sapped 
the vitality. Toward its close expectorants are even more useful 
than in croupous pneumonia, and every care should be taken that 
the catarrhal process does not pass by insidious degrees into a hidden 
tuberculosis. Tubercular infection should be suspected in all cases 
in which recovery is abnormally slow. 

PRURITUS. 

Itching of the skin or mucous membranes about the openings of 
the body is a very common state, and while it may be dependent 
upon local causes, such as hemorrhoids in the case of pruritus ani, it 
more commonly is due to some systemic condition, such as debility, 
diabetes, gout, or renal disease, or other similar causes. The treat- 
ment consists, first, in the removal of the cause, and, next, in the 
local treatment of the condition. There is generally no redness 
or eruption, except that due to scratching. 

Internally, arsenic, quinine, bitter tonics, cod-liver oil, alkaline 
diuretics, or mineral waters are useful in debilitated cases, and an 
avoidance of condiments, such as mustard or pepper, is needful if 
the disease affects the orifice of the bowel, urethra or vagina. 

The local treatment of pruritus consists in the use of lotions, 
salves, or ointments made up of various constituents, a number of 
which are capable of acting as local anesthetics. Very often bathing 
the parts with 1 dram of bicarbonate of sodium or of borax to a pint 



902 



DISEASES 



of cold water gives relief temporarily, or the following formulae will 
be of service: 



Oi 



3— Phenolis f 3J vel 5ij (4.0-8.0) 

Aquae destillatae q. s. ad Oj (480 cc) . — M. 

S. — Apply as a lotion several times a day. 

1$ — Liquoris carbonis detergen 1 f 3ij (8.0) 

Aquas destillatae q. s. ad Oj (480 cc). — M. 

S. — Apply as a lotion. 



be 



loridi mitis 


• • • 5J (4.0) 




gr. xxx (2.0") 




. . . ■ f 5i (4.0) 




. . . gr. xv (1.0) 




... 5ij (8.0) 


fdrosi 


... Sij (60.0).— M 



Or an ointment made as follows is serviceable: 

3— Phenolis gtt. v. vel xx (0.3-1.3) 

Adipis benzoinati 5 j (30.0) 

Petrolati 3j (4.0).— M. 

S. — Apply as an ointment. 

In other cases 10 to 20 minims (0.6-1.3) of chloroform may 
used in place of the phenol. 

Still another formula is as follows: 

]$ — Hydrargyri c 

Phenolis 

Picis liquidae 

Mentholis . 

Zinci oxidi 

Adipis lanse hy 
Ft. unguentum. 
S. — Apply with gentle rubbing to the parts twice a day after cleansing them 

The injection into the rectum of about 2 ounces (60.0) of fluid- 
extract of hydrastis night and morning may also be advantageous. 

Cocaine may be painted over the parts, but it should rarely be 
used in ointment, as fats prevent its acting effectively. It should 
also be remembered that the anal and vaginal mucous membranes 
are so thick that strong solutions of cocaine are necessary to produce 
anesthesia, and that the effects of cocaine are only temporary. 
Cocaine is useless when applied to the skin. Where the itching is 
very obstinate the parts may be painted with a solution of nitrate 
of silver of the strength of 20 grains (1.3) to the ounce (30.0) of 
water, cocaine having been previously applied to relieve the pain of 
the application. (See also article on Cold.) In diabetic pruritus 
vulvae, brewers' yeast, in the proportion of a tablespoonful to a 
quart of water, may be used on a compress to reduce the sugar which 
irritates the parts involved. 

Allingham has used with advantage a piece of ivory shaped like 
a rubber nipple and provided with a circular shield. This is slipped 
into the bowel at night and serves to keep the surfaces apart. 

In cases of general pruritus baths are often of great service. They 
may consist in plain hot-water baths or Turkish baths. In other 
instances, to each bath of 30 gallons may be added J pound of bicar- 
bonate of sodium, or 1 to 4 ounces (30.0-120.0) of borax may be 
used. When the skin is very irritated starch, 1 pound (480), or 



1 For method of preparing this liquid, see article on Eczema. 



PUERPERAL DISEASES 903 

bran, 2 pounds (960), may be added to the bath. Sometimes lin- 
seed-meal baths may be used. The meal is placed in hot water until 
the glutinous matter is set free, when it is added to the bath. One 
or two pounds (480-960) are used. In very persistent cases the 
patient may actually eat and sleep in the bath with advantage. 

PUERPERAL DISEASES. 

The diseases of the puerperium may be divided into two broad 
classes— infectious and non-infectious. The first class should be 
further subdivided into (1) those infectious diseases in which the 
point of infection has been somewhere along the parturient tract, and 
(2) those in which the infection has entered the body by some other 
channel. Under subheading 1 come all those diseases grouped 
under the generic term " puerperal fever," "puerperal septicemia," 
"puerperal infection," and the like, none of which truly expresses 
the condition. If it is necessary in medical nomenclature to have a 
single term which shall denote infection of the genitalia after delivery, 
a word should be coined strictly limited in sense to mean the patho- 
logical conditions which result from the activity of pathogenic bac- 
teria along the whole genital tract. This classification is necessary 
for a clear and systematic description of the treatment of diseases 
in the puerperal state. 

The Treatment of Infection along the Genital Tract after Labor. — 
Uterine cultures show that about 90 per cent, of the infections of 
the genital canal are due to streptococci; but blood cultures show 
that many of these infections are local and not general, the strepto- 
cocci acting as saprophytes on the endometrium, and not penetrating 
the subjacent protective layer of granulation cells. If the micro- 
organisms can be destroyed and the infected, necrotic endometrium 
is removed, the symptoms of infection disappear as does the danger 
of systemic invasion. 

The writer's routine application of this principle in practice is as 
follows: If the temperature after delivery remains over 101° F. 
for twenty-four hours without evident cause independent of the 
genitalia, he washes out the uterine cavity with Lugol's solution, 
2 drams to the quart (2.0-1000). To ensure the entrance of the 
antiseptic fluid to the fundus and its free exit from the cervical canal 
an intra-uterine catheter is desirable. The best is Fritsch's modi- 
fication of Bozeman's catheter. If, however, the cervical canal is 
patulous, as it usually is after labor, a catheter attached to a Davidson 
or fountain syringe answers the purpose perfectly. 

In many cases this treatment brings the temperature down to 
normal within twenty-four hours. If fever does not disappear within 
this time or perhaps rises even higher, the second indication must 
be met. The uterine cavity should be explored to be sure that there 
is no mass of necrotic endometrium, decomposing blood clots or 



904 DISEASES 

fragments of putrefying placenta. It is obvious that this procedure 
is not a curettage of the puerperal uterus which at one time was 
considered essential but is now never resorted to, as there is danger 
of implanting infection in the uterine wall. The reaction against 
the former practice has been so great that many specialists advocate 
no treatment of the uterine cavity at all; simply the Fowler position 
and natural drainage. But it would seem sound surgical common 
sense to investigate the condition of any infected body cavity to 
be sure that there was no mass of necrotic material in it to furnish 
fresh nidus of infection. This is best accomplished by the use of 
the placental forceps, care being taken to guard the uterine wall 
from injury; for not only can the uterine muscle be perforated by 
an instrument in clumsy hands, but slight wounds of the uterine 
wall may be enough to inoculate the general system with the germs 
whose activity has been before confined to the uterine cavity, by 
penetrating the layer of granulation cells under the endometrium. 

The writer's manner of employing this plan of treatment after 
labor is as follows: 

A cleansing and disinfecting uterine douche is given in order to 
disinfect the field of operation (Lugol's solution f3ij-Oij). 

Next the placental forceps is inserted, and an effort made to grasp 
any material lying loose within the cavity or still attached to the 
uterine walls. It is usually best to repeat the maneuver several 
times until nothing more is brought away except a little clear blood. 

Then the uterine cavity is again thoroughly washed out. Occa- 
sionally it is necessary to repeat the irrigation for several successive 
days, but rarely the instrumental exploration and evacuation of 
the uterus. If this treatment is unsuccessful and the temperature 
remains elevated in spite of irrigation and the use of the placental 
forceps, one must assume either that general systemic infection has 
occurred, or that an inflammatory action has begun in the uterine 
walls, in the pelvic connective tissue, or within the tubes. In case 
of general infection, the treatment is to support the body-cells in 
the combat which they must wage with the invading microorganisms. 
This is best accomplished by the administration of as large a quan- 
tity of nutriment as the patient can stand without rebellion of the 
stomach or bowels, and the exhibition of alcoholic stimulant. Full 
doses of whisky were at one time thought to be essential. Digitalis 
and strychnine are indicated by a feeble rapid pulse. Occasionally 
measures are required to reduce an excessive elevation of the tem- 
perature, but this is best avoided as long as possible, for antipyretic 
treatment is usually depressing and ill-suited to the patient's 
adynamic condition. 

The use of antistreptococcic serum, streptococcic vaccines, and 
injections of normal salt solution are important adjuvants to the 
treatment, which should not be neglected in a serious case. Intra- 
venous injection of collargol, fixation abscess, and the injection 



PUERPERAL DISEASES 905 

of healthy human or horse serum should also be considered. With 
this plan of treatment about three-fourths of the cases of general 
septic infection after labor recover. Sometimes metastasis to 
important organs occurs so early as to render all treatment of no 
avail. Occasionally septic peritonitis develops rapidly and to an 
extensive degree. It is in such cases that celiotomy, flushing, and 
draining the peritoneal cavity occasionally save life. The physician 
must guard himself, however, from operating too early and unneces- 
sarily. After operation, drainage of the peritoneal cavity is an 
essential feature of the treatment, even although the evidence of 
suppuration within the cavity is slight. Localized abscesses any- 
where in the pelvis or abdomen indicate incision and drainage. In 
the early stages of the peritoneal infection, if the subject is vigorous, 
not exhausted by a prolonged labor or other depressing causes, 
the administration of saline purgatives in concentrated solution 
often effects brilliant results. 

The writer's custom is to give a dessertspoonful of a concentrated 
solution of Epsom salt every fifteen minutes until free evacuation 
of the bowels is secured. He has seen the temperature reduced by 
this plan of treatment from 104° F. to normal in the course of twelve 
hours, and with the reduction of temperature all the symptoms of 
peritonitis, which were well marked, entirely disappeared. 

Infection of the parturient tract may occur any where • from the 
fundus of the uterus to the vulvar outlet; therefore, the practitioner 
should examine carefully all the lower parturient tract in order to 
detect, if possible, an ulcerated surface covered by false membrane, 
which if overlooked might be the entrance-point for a fatal infection. 
These unhealthy surfaces are best detected by the skeleton specu- 
lum of heavy wire. If an unhealthy, ulcerated wound is thus dis- 
covered, the writer's practice is to apply to it a solution of nitrate 
of silver 40 to 60 grains to the ounce (2.6-4.0:30). This application 
promotes an exfoliation of the unhealthy membrane and the appear- 
ance of healthy granulation tissue within a few days. 

The most common point of infection outside the parturient tract 
after labor is some portion of the urinary apparatus, usually the 
bladder. Parturition necessarily diminishes the vitality of the 
vesical mucous membrane by the pressure and stretching to which 
it is subjected. After labor, therefore, it is not in a condition to 
resist the attacks of microorganisms, should these in any way gain 
access to the vesical cavity. Most commonly microbes are intro- 
duced into the bladder by a catheter. This, however, is not neces- 
sary, as it has been demonstrated that they can wander from the 
vaginal canal through the urethra into the bladder. Once arrived 
within the bladder, the microbes attack the depressed bladder cells, 
and may invade the vesical mucous membrane. This is manifested 
by the usual symptoms of septic cystitis— fever, pus in the urine, 
pain on pressure over the hypogastrium, and painful, frequent 



906 DISEASES 

micturition. The duration of these symptoms is, as a rule, not 
very long. The fever subsides and the symptoms of cystitis dis- 
appear. After an interval of some days, however, there is again a 
sharp outbreak of fever, with pain in the region of the kidneys, the 
reappearance of pus, or at least of numerous bacteria, in the urine, 
and a marked leucocytosis. This indicates a septic infection of the 
pelves of the kidneys after the microorganisms have migrated along 
the ureters. During their migration their presence has not been 
manifested by any symptoms. In the majority of cases even the 
symptoms of pyelitis disappear after a time, and the patient makes 
a good recovery; but in a certain proportion there is a systemic 
infection from the kidneys. There may be extensive suppuration 
of the kidneys and surrounding tissue, with fatal results, or, as the 
writer has seen in several cases, the symptoms of general systemic 
infection become so grave as for a long time to threaten the patient's 
life. In the worst cases of bladder infection the mucous lining 
sloughs, peritonitis develops, and the patient dies before the disease 
has time to infect the kidneys. 

The practitioner, bearing in mind the serious consequences of sep- 
tic cystitis after labor, should always be on the watch for it, and 
should adopt an energetic treatment immediately upon its detection. 
A thorough disinfection of the bladder will remove all present symp- 
toms, and prevent the occurrence of grave and possibly fatal after- 
complications. To accomplish this purpose the writer employs a 
saturated solution of boric acid. One injection of a quart of this 
solution through a two-way catheter is usually sufficient. Occa- 
sionally it is necessary to repeat it or to follow it by several injections 
of boric-acid solution. A 1:5000 oxy cyanide of mercury solution 
may be employed if the first boric-acid injection fails to improve 
the local symptoms. 

After the irrigation of the bladder 4 ounces of a 25 per cent, argyrol, 
or a 5 per cent, emulsion of iodide of silver, a 1 per cent, solution of 
hegonon or a 20 per cent, solution of silvol is injected and allowed to 
remain until the next spontaneous urination. 

If infection of the kidneys ensues, a stimulating and supportive 
plan of treatment with salol, milk diet, and uro tropin is indicated. 
The pelves of the kidneys should be washed out through the two- 
way ureteral catheter and then injected with one of the silver salts 
in weak solution. If extensive suppuration occurs in the kidneys, 
the pelves may be opened and drained by lumbar incisions, or if the 
suppuration is confined to one kidney, nephrectomy may be indicated. 

Perhaps the most uncommon point of septic infection after labor 
is the rectum. The writer has, however, seen one fatal case of this 
sort— from the use, no doubt, of a dirty syringe-nozzle in the hands 
of a careless nurse. Septic proctitis is treated by boracic-acid solu- 
tion irrigations and iodoform (5 grains) suppositories. 

Next in frequency to the parturient tract and the urinary system 



PUERPERAL DISEASES 907 

as a region prone to infection after labor comes the breasts. Infec- 
tion of the nipples, and a consequent mammary inflammation or 
suppuration, is one of the most troublesome minor complications 
that the obstetrician is called upon to treat. By careful prepara- 
tion of the nipple during the last month of pregnancy, by extreme 
care to secure perfect cleanliness during the period of lactation, by 
emptying the breast and supporting it with a mammary binder, 
infection of the breast can almost surely be avoided. If it occurs, 
the first effort should be to limit its extent and degree, and to prevent, 
if possible, suppuration. The best means to accomplish this end 
are derivation of the blood from the mammary glands by an active 
purge, compression of the gland-substance, and support of the 
breasts by a suitable mammary binder. 

To these should be added, in the acute stage of inflammation, 
fomentations of very hot water, or the ice-bag, and, later, the appli- 
cation of cloths wrung out in alcohol and lead water, renewed 
every three hours, or a saturated solution of magnesium sulphate 
may be substituted. Unless the infection has been of a virulent 
nature and the amount of infective material large, this plan of treat- 
ment allays the inflammation and prevents suppuration. 

Bier's cups to create a local hyperemia are recommended by 
some, but the writer has found them painful to the patient and 
not as efficient as the treatment just described. 

The other infectious fevers of the puerperal state include the 
infectious diseases which might affect any adult female, and their 
treatment differs in no respect during the puerperium from that 
adopted under other circumstances unless there should be local 
complications. 

Non-infectious Diseases of the Puerperium. 

Anomalies of I?ivohdion .—Suiper'm volution, an exaggeration of that 
process by which the uterus is reduced to its normal size after labor, 
manifests itself, as a rule, only after the puerperal state is completed, 
and therefore its treatment need not be considered. 

Subinvolution, an arrested or retarded return of the uterus to its 
normal condition and dimensions after labor, is one of the common- 
est complications with which the obstetrician has to deal in the 
management of the puerperium. The cause of subinvolution is 
always a local one. General conditions, as acute fevers, have no 
influence whatever upon the process of involution unless they are 
accompanied by some local complication. 

There are two causes of subinvolution. The involution may be 
prevented by anything which brings an excessive amount of blood 
to the uterine body, as, for instance, small fibroids within its walls 
or hypertrophied deciduous membrane remaining adherent to its 
inner surface. Or subinvolution may be the result of mechanical 



908 DISEASES 

obstruction to the contraction of the uterine walls. An example 
is a retained placenta or a submucous fibroid or adhesions dragging 
the uterus out of place and preventing its contraction, or often an 
overdistended bladder and rectum. 

In hyperemia of the uterus the cause of an excessive blood- 
supply must be sought and removed before the subinvolution can 
be remedied. 

If small fibroids can be detected, the administration of ergotin 
1 grain, hydrastinin \ grain, and stypticin 1 grain, in pill form, 
has been found most useful. Pituitrin (1 cc of 20 per cent, solu- 
tion) is undoubtedly one of the strongest stimulants to uterine con- 
traction. If there is an hypertrophied endometrium retained within 
the uterus, a dull curette may be cautiously employed to remove it. 
In cases of heart disease in which the blood-current is sluggish and 
dammed back into the large veins of the trunk, digitalis is the most 
effective remedy to overcome the subinvolution. There may be 
an active hyperemia associated with inflammatory action, either in 
the uterine wall or upon its peritoneal covering or in its adnexa; in 
this case the inflammation must be overcome by disinfection, the 
use of purgatives, the local application of hot water, or possibly 
operative treatment, before involution can be secured. When there 
is mechanical obstruction to the return of the womb to its normal 
dimensions, the hindrance must, of course, be removed before one 
can expect a good result from treatment. Retained placenta must 
be removed. Submucous fibroids should be enucleated. 

Every labor results in some injury of the maternal structures. 
Usually they are slight in degree, manifesting no symptoms and 
healing spontaneously. Occasionally the injury results in fistula 
communicating with the bladder or rectum, in deep granulating 
wounds in the vagina, or in ulcerated sores. 

In the case of fistula a cure can sometimes be effected without 
operative interference by touching up the edges of the fistulous 
tract with nitric acid, in order to excite an outpouring of granulation 
tissue in the hope that it may plug the opening. In deep tears, 
which have not been primarily united, application of a solution of 
nitrate of silver will hasten the cure and prevent infection of the 
wounded surface. If ulceration occurs, the ulcerated spots are to 
be carefully watched and treated in the same manner. All the 
injuries of the birth-canal should be repaired by primary, inter- 
mediate, or secondary operation. 

Hemorrhages from the birth-canal after labor depends upon a 
number of well-known causes, which must be sought out and corrected 
before the bleeding will cease. Most frequently the cause of a 
hemorrhage will be found in retained placental fragments, which 
must be removed. Frequently displacements of the uterus will be 
found as a cause, and correction of the displacement will check the 
bleeding. 



PUERPERAL DISEASES 909 

In interstitial bleeding after labor, resulting in hematoma, care 
must be taken to preserve the parts in as aseptic a condition as 
possible, while an attempt is made to limit the bleeding by the 
application of direct cold, preferably by means of a colpeurynter 
dilated with ice-water, which must be removed from time to time 
in order to allow the lochia to escape. After rupture or incision 
of these blood-tumors the cavity left behind must be carefully 
disinfected with tincture of iodine, and, if necessary to control further 
bleeding, well packed with iodoform gauze. 

Of all forms of bleeding, that which occurs directly after labor 
in consequence of inertia uteri, known as post-partum hemorrhage, 
is the most frequent, the most alarming and dangerous in its mani- 
festations and consequences. No one should attend a case of 
obstetrics without having in mind a clearly defined program to be 
put in immediate execution when called upon to deal with this 
frequent and dangerous complication. There are two indications 
to be met: first, to control the hemorrhage, and, second, to treat 
the after-condition. The first indication is met by the following 
plan of treatment: 

External stimulation of the uterus by kneading and rubbing through 
abdominal walls, as is practised in Crede's method of expressing the 
placenta. 

If this fails carry the aseptic (gloved) hand into the uterus and 
remove any blood-clots, pieces of placenta or membrane that may 
be found there, and manipulate the parts so that the internal surface 
of the uterine walls is irritated by the movements of the operator's 
fingers. 

The most certain and effective treatment is packing the uterine 
cavity with plain sterile or iodoform gauze. Too much time should 
not be wasted on other measures before resorting to the intra-uterine 
pack. 

The physician should give ergot, or "ergot aseptic" in full dose 
hypodermically with pituitrin added. 

Drugs, as the styptic salts of iron, and especially Monsel's solution, 
have been recommended from time to time as intra-uterine applica- 
tions in the case of post-partum hemorrhage, but they are dangerous, 
for the coagulation produced by them may extend far into the 
uterine vessels, and the clots can only be broken up by putrefaction, 
exposing the patient to the danger of septic poisoning. 

Excessive hemorrhage (post-partum) from lacerations along the 
genital canal can be controlled by well-placed sutures. 

Bearing in mind this plan of treatment, it is not likely that an 
intelligent and skilful practitioner will lose a case of postpartum 
hemorrhage. 

Treatment of the After-condition.— While the physician is engaged 
in controlling the hemorrhage the nurse should administer a hypo- 
dermic injection of caffeine sodium benzoate or of camphorated oil, 



910 DISEASES 

if symptoms of shock or collapse are manifested. After the bleeding 
has ceased it is well to administer salt solution by the bowel by 
Murphy's method (see Peritonitis), which maintains the patient's 
temperature, relieves the shock, and by its irritation promotes 
contraction of the uterine muscle. The submammary or intra- 
venous injection of normal salt solution is more efficient than the 
enteroclysis, but more difficult for the ordinary physician to admin- 
ister. In desperate cases the patient should receive adrenalin and 
strophanthin or strophanthone intravenously. This should be suc- 
ceeded by small doses of hot, strong brandy and water, and a little 
warm milk if the stomach will retain it. As soon as reaction is 
well established a half-pint (240 cc) of hot beef-tea should be 
administered, and a hypodermic of J grain (0.008) of morphine given, 
in order to secure quiet and rest and to get the stimulant qualities 
which this drug undoubtedly possesses. 4 Occasionally measures must 
be adopted to retain enough blood within the large vessels and in the 
heart to prevent excessive cerebral anemia or cardiac failure. This 
is best done by autotransfusion : that is, by bandaging the extremi- 
ties from below upward, in order to secure as large a quantity of 
blood as possible within the vessels of the trunk and brain. Intra- 
venous injection of a 0.9 per cent, solution of common salt is required 
where there are profound exhaustion and depression after hemor- 
rhage. If it is impracticable to throw this solution directly into 
the bloodvessels, an interstitial injection seems to answer the purpose 
equally well. The most convenient place for such injections in 
females is under the breasts. (See Hypodermoclysis, Part III.) 
Actual transfusion by the citrate of sodium method has given bril- 
liant results in the most desperate cases. 

The milk secretion during the puerperal state presents abnormal- 
ities which call for treatment. One may have to deal with anomalies 
of quantity or quality. The most frequent anomaly of quantity 
in milk secretion is unfortunately one of deficiency. Insufficient 
milk-supply depends on a number of causes. Perhaps the most 
frequent is a lack of development of the glandular tissue, and in 
this form of insufficient milk secretion no treatment can be of avail. 
When the lack of milk is due to some intercurrent affection in the 
puerperal state the treatment must be directed toward this com- 
plication before the milk-supply can be reestablished in normal 
quantity. It may be the consequence of hemorrhages or of diar- 
rhea, or the result of an acute febrile attack during lactation, or of 
inflammation within the gland itself. Serious organic disease may 
also be a cause, and insufficient nourishment must be held account- 
able in some cases. Profound emotions exert an extraordinary 
influence upon lactation in altering both the quantity and the quality 
of the milk. It has long been supposed that the return of menstru- 
ation has a disastrous influence upon milk secretion. This, however, 
has been definitely disproved by careful observations. The return 



PUERPERAL DISEASES 911 

of normal menstruation without complications has no apparent 
influence, as a rule, upon the quantity or quality of the woman's 
milk. In all the temporary diseases interfering with milk secretion 
described above, it should be borne in mind that on the disappearance 
of the abnormal general or local condition milk secretion can be 
successfully reestablished even though it be absent for days or 
weeks. Electricity has been much vaunted as a remedy for insuffi- 
cient lactation. It may be applicable in cases of torpidity of the 
mammary gland or in those cases where lactation has been suppressed 
on the birth of a first child, and where the mammary gland, therefore, 
does not respond readily to the stimulus of subsequent births. This 
remedy will, however, often prove ineffective and disappointing. 

The use of Bier's cups to produce local hyperemia is logical and 
has proved efficient. 

Pituitrin has been shown to be a galactogogue in animals and 
possibly in women. It may be given by the mouth or hypodermic- 
ally, and it has seemed to the writer to be efficient. Placental 
extract is at present under trial for this purpose. 

Instances of excessive milk secretion are not infrequently met 
with. The milder and simpler forms can be managed by regulation 
of the diet and free purgation. Galactorrhea, a constant flow of 
milk from the breasts, is one of the most stubborn forms of exces- 
sive milk secretion. Two measures can usually be relied on to give 
relief: firm compression of the mammary gland with the application 
of belladonna ointment, and the administration internally of iodide 
of potassium. In some cases of this character milk secretion stops 
spontaneously with the return of menstruation, and in a certain 
proportion of cases a treatment to secure a discharge of blood from 
the uterus has been successful in stopping the flow of milk. Success 
has been obtained with Simpson's plan of introducing a piece of 
caustic within the uterus in order to bring back the menstrual flow, 
but this local treatment has been superseded by the safer plan of 
applying the negative pole of a galvanic current (15 milliamperes) 
in utero. Warm douches have been used successfully. Electricity 
to the mammary glands has been recommended to secure the proper 
contraction of the sphincter muscles of the lactiferous ducts, but as 
this is a result, and not a cause, of the galactorrhea, electricity 
proves ineffective. The long-continued administration of ergot has 
been warmly recommended. The remedy should be tried, for its 
use is rational. Chloral has been shown to be very effective in 
diminishing the quantity of milk. This drug, therefore, is worthy 
of trial. It has been declared that antipyrine, in 2^-grain (0.15) 
doses three times a day, will diminish milk secretion. The drug, 
however, has not been tested often enough to demonstrate its power. 
Quantitative anomalies in the milk secretion most often depend 
upon an ill-regulated diet. A fatty diet diminishes the quantity 
of milk; a vegetable diet diminishes the casein, and fat increases 



912 DISEASES 

the sugar; a diet rich in meat, especially if reinforced with alcoholic 
stimulants, increases the fat and casein, but diminishes the sugar. 
If the mother's milk is evidently disagreeing with the nursing infant, 
a chemical analysis of it should be made, and on the result rules 
regulating the diet should be adopted. The most common mistake 
in practice is to overfeed a nursing woman, especially with a milk 
diet, with the idea which prevails extensively among the laity that 
the cows' milk poured into the stomach appears again in the mam- 
mary gland. It is usually sufficient for a nursing woman to observe 
the ordinary diet which agrees with her under all circumstances, with 
the addition of a half -pint of milk midway between the morning and 
midday and midday and evening meals. Occasionally a wineglass- 
ful of malt at the midday and evening meals is a useful addition to 
the diet, and in anemic patients the addition to the malt of 5 grains 
(0.3) of pyrophosphate of iron is an advantage. 

There is found in every pregnant woman some alteration in the 
constitution of the blood, which consists, roughly speaking, of a 
diminution of the red blood-corpuscles and of the albumin and the 
iron in the blood, with an increase in the white blood-corpuscles 
and the serum. In some cases this change is much exaggerated, so 
that an intense degree of anemia appears in the puerperal state which, 
in its severity, simulates pernicious anemia or some fatal form of 
blood disease. The anemia of puerperal women, however, even in 
severe cases, usually yields to treatment. After the continued use 
of Blaud's pills the writer has seen the blood corpuscles rise from 
less than three to nearly four and a half millions, and the hemoglobin 
increase from 40 to 75 per cent, in a few weeks. In some cases 
arsenic alone succeeds where iron fails completely. If a quick 
result is desired the best treatment is the hypodermic injection of 
citrate of iron and cacodylate of sodium. 

Eclampsia. 

To treat eclampsia intelligently and successfully it is necessary 
to understand its etiology as fully as modern knowledge permits. 
Although the subject needs more light from future investigations, 
enough is now known to justify the following statement: 

1. The cell-activity of mother and fetus produces toxins which 
are poisonous to the whole organism unless they are voided or made 
harmless by the excretory organs. 1 

2. The organs in the childbearing woman are often inadequate to 
produce antidotes to or to eliminate these toxins. 

3. Consequently, poisons, of a nature not yet demonstrated, are 
stored up in the maternal blood until, by cumulative action, their 
presence is manifested in the eclamptic seizure and other symptoms. 

1 Harold, C. Ernst, American System of Obstetrics, vol. ii, p. 431. 



PUERPERAL DISEASES 913 

4. The convulsions are probably the result of an acute cerebral 
anemia brought about by violent contraction of the arterioles. As 
a result of intense muscular action the circulation is interfered with, 
and blood is determined into non-muscular regions, as the brain, 
lungs, kidneys, etc., to such a degree that the congestion of these 
parts becomes dangerous, leading to apoplexy in the brain, edema 
in the lungs, and often a complete abrogation of renal function. 

The toxins exert an effect upon the lobules of the liver like phos- 
phorus or chloroform, causing degeneration of the cells. The indi- 
cations for treatment in convulsive seizures of this nature are plain: 

First, to eliminate the toxins from the blood as quickly and in 
as large quantities as possible. Second, to diminish nervous sensi- 
bility and lessen muscular power, in order to reduce the convulsions 
in vehemence, duration, and frequency. Third, if convulsions occur 
during labor, to save the infant without adding to the risk of the 
mother. Fourth, to guard the woman from injury during the 
attack. 

The first indication is met by venesection, diaphoresis, and cath- 
arsis. By the first, one eliminates a certain quantity of poison 
along with the blood and relaxes the muscles. If there is sharp post- 
partum hemorrhage, or if the patient is from any cause weak and 
anemic, blood-letting is not called for. In the ordinary case, how- 
ever, with full pulse, congested head, the veins standing out upon 
the neck and face, and a high blood-pressure, venesection is an 
an undoubted advantage. While the median basilic of one or both 
arms is being opened some croton oil should be sent for, and 2 
minims (0.1) mixed with sweet oil may be placed upon the tongue. 
As the stomach and intestines may add to the toxemia by absorp- 
tion of their contents, the stomach should be washed out with the 
stomach-pump and the colon should be irrigated. If the stomach 
pump is used the laxative can best be administered through it, 2 
ounces of castor oil with 2 minims croton oil added can be directly 
introduced into the stomach. Directions should at the same time 
be given to wring out four blankets in hot water; these are wrapped 
around the legs, trunk and arms, and well covered over with one 
or more dry blankets. A steam bath in a portable cabinet, or 
immersion of the patient's body in a bath-tub full of hot water 
(99° F.), is more efficient if practicable. A submammary injection 
of a pint of normal salt solution is a valuable aid in producing free 
diaphoresis. The sweating thus induced is profuse. An ice-bag 
must be put to the head to prevent overcongestion of the brain. If 
the patient does not sweat well, salt solution should not be injected. 
The sweats and injection of fluid should alternate two hours apart, 
but the fluid after the first injection should be by the bowel, and 
instead of salt solution it is now an accepted practice to instil into 
the bowel, by the Murphy method, bicarbonate of sodium solution 
3j-Oij to combat the acidosis which is usually present in eclampsia. 
58 



914 DISEASES 

In this way, directly and indirectly through the skin and bowels, 
one eliminates the cause of eclamptic convulsions as quickly and 
thoroughly as possible from the blood. The latter may be acted 
upon by f grain of elaterium rubbed up in butter, or by compound 
jalap powder and calomel, instead of the croton oil. If the patient 
cannot swallow, the stomach-pump may be used as already stated 
to introduce castor oil into the stomach. Pilocarpine seemed at 
one time an ideal remedy to secure diaphoresis in eclamptic cases, 
but it has fallen into well-deserved disrepute. It much increases 
the danger of pulmonary edema, and is too profound a depressant. 
It is no longer employed by experienced obstetricians, except in 
post-partum eclampsia, when the hot baths do not result in a satis- 
factory sweat. 

The second indication is best met by morphine in full doses. 
Stroganoff who advocates the sedative treatment in eclampsia as 
most important, insists on absolute quiet. Avoidance of all physical 
and psychical initiation and the narcotization of the patient. He 
and his followers have secured a remarkably low mortality by this 
treatment. 

Anesthetics are of little use. Chloroform employed for any 
length of time produces the same hepatic degeneration as the toxins 
of eclampsia, and ether damages the kidneys. 

If convulsions come on during labor, the child should be rapidly 
extracted as soon as the os is well dilated, but not before, because 
efforts to dilate the os cause shock, increase the convulsions, and 
distract the physician's attention from the woman's most threaten- 
ing danger. Moreover, the os usually dilates with rapidity during 
eclampsia. 

In consequence of experiments showing the relationship between 
the parathyroids and tetany, parathyroid extract in 1-grain doses is 
a logical addition to the treatment and has appeared to be effective. 

The high blood-pressure of eclampsia is recognized as one of its 
dangers; measures to reduce the systolic pressure should always be 
considered. The most effective are blood-letting, puncture of the 
membranes, sweating, veratrum viride (see Part II), and nitro- 
glycerin. Lumbar puncture is receiving a trial, but it is too soon to 
judge of its effect. 

The only injury to be feared during eclamptic attacks is wounds 
of the tongue from the teeth. They can be prevented by inserting 
between the teeth a brush-handle wrapped in a handkerchief or by 
drawing a towel into the mouth like a bit. Well-meaning but 
ignorant bystanders sometimes throw themselves upon an eclamptic 
patient to restrain her convulsions by force. This should be 
forbidden. 

RETINITIS. 

Retinitis, or inflammation of the retina, is commonly the result 
of constitutional diseases, for example, Bright's disease, diabetes, 



RHEUMATISM 915 

syphilis, etc., of altered states of the blood and bloodvessels, infec- 
tions, toxins and traumatisms, or it may be due to the extension of 
a diseased process from an inflamed iris, ciliary body or choroid. 
The general remedies must be directed according to the cause, and 
the eyes must be protected from light, and all close work avoided. 
Very distinct retinal irritation may be caused by eye-strain, which 
is to be relieved by the prolonged use of atropine and dark glasses, 
and later suitable lenses for the correction of any existing error in 
refraction. 

RHEUMATISM (ACUTE ARTICULAR). 

No better example of the fact that therapeutics is in advance of 
pathology can be adduced than the disease known as acute 
rheumatism. The therapeutist cannot tell how he cures the con- 
dition designated by this name, simply because the pathologist can- 
not tell what the cause of the disease is. At the present time it 
would seem probable that the salicylates exercise a good effect by 
affecting a specific microorganism or its educts. It must be remem- 
bered, however, that all cases of acute multiple arthritis are not 
articular rheumatism. In many cases they are due to the gono- 
coccus, the pneumococcus, or other pathogenic germs, and in all 
such instances the salicylates are useless. (See Vaccine and Phyla- 
cogens.) 

The treatment of acute articular rheumatism is divided into that 
portion devoted to the cure of the disease-process, and that directed 
to the relief of the pain and of the other and local manifestations of 
the disease. 

A solution of bicarbonate of sodium, 20 grains to the ounce (1.3- 
30.0), may be applied to the joints involved, by means of lint wet 
with this solution, with diminution of the sense of heat or burning, 
or ice-cold compresses may be tried. In other cases relief may be 
obtained by applying hot cloths saturated with the so-called Fuller's 
lotion— namely, carbonate of sodium 6 drams (24.0), laudanum 10 
ounces (300.0), glycerine 2 ounces (60.'0), and water 9 ounces (270.0). 
Sometimes much benefit can be obtained by fixation of the joints 
by means of splints. Dressings kept wet with a saturated solution 
of magnesium sulphate are very useful. 

A most valuable application to the inflamed joints of rheumatism, 
and the one the author has employed for many years to the exclusion 
of all others both during the acute stage and afterward when they 
remain swollen and enlarged, is: 

T$— Ichthyolis 3ij (60.0) 

Adipis lanse hydrosi • 5ij (60.0). — M. 

S. — Smear thickly over the joint and apply on lint in addition. 



916 DISEASES 

In other cases the acute stages of the inflammation may be com- 
bated with advantage, particularly when there is gastric disorder, 
by the local application of salicylic acid made into an ointment with 
an animal fat, not vaseline or glycerin, as it is not absorbed when 
so mixed. According to Bouget, this treatment is best suited to 
blondes and young persons, as absorption is more rapid in this class 
of patients. The following salve may be prescribed: 

1$ — Acidi salicylici 3j (4.0) 

Olei terebinthinse lUxxx (2.0) 

Adipis lanae hydrosi 5j (30.0). — M. 

High fever is to be controlled by the same measures as the high 
fever of any other disease— by cool sponging, or sponging with 
tepid water, and sometimes by the use of antipyretic drugs, the use 
of which is more justifiable in this case than in ordinary fevers in that 
they tend to relieve the pain. 

Immediately on seeing the patient the physician should resort to 
salicylic acid or its salts. It is worthy of note that good results 
generally follow rapidly; that is, the salicylates give relief in from 
three to four days, or fail altogether. It is most important to 
remember that salicylic acid protects the cardiac valves and the 
entire endocardium from the ravages of the disease only by shorten- 
ing the attack, and not by any direct influence; and in addition that 
this acid, by reason of the profuse sweats often produced by it and 
its tendency to cause cardiac depression, must be watched lest.it 
act unfavorably on the general systemic state. 

The proper use of salicylic acid is often misunderstood, and it 
fails to produce good results sometimes because of this fact. When- 
ever acute articular rheumatism appears the salicylic acid should 
be pushed in the same way that we use quinine on the advent of a 
malarial paroxysm— namely, in full dose. 

It is useless to give salicylates in 5- or 10-grain (0.3-0.6) doses 
three times a day; they must be given in 20- to 30-grain (1.3-2.0) 
doses or more, morning, noon, and night, or oftener, or not at all. If 
the sweats are too severe or the stomach rebels, they may be stopped, 
but not decreased in amount unless for good reason. Further than 
this, if salicylic acid is used for three or four days in this way, and 
produces evidences of cinchonism, yet fails to alter materially the 
course or severity of the trouble, it should be withdrawn, as it will 
rarely if ever do any good after this time because the disease is 
due to an infection of the joints by some microorganisms upon 
which the salicylates have no influence and vaccino-therapy may 
be essential. (See Vaccine Therapy, Phylacogens, and article on 
Salicylic Acid, Aspirin, and Novaspirin.) 

Lees also asserts that the salicylates often fail in acute rheumatism 
because the dose is not large enough. He advocates as much as 300 
grains a day to a child, and insists that large doses of bicarbonate 



RHEUMATISM 917 

of sodium are necessary to prevent evil effects from these doses. 
The chief of these is "air hunger" or dyspnea. The author would 
be afraid to use such large amounts, but this view of Lees emphasizes 
the fact that the doses used are often too small. 

In the author's experience the salicylate of strontium is a very 
useful substitute for the acid, as it is less apt to irritate the stomach. 

Clinical experience seems to show that if sodium bicarbonate is 
given in full doses with the salicylates, better results are obtained 
than if the salicylate is used alone. The dose of the bicarbonate of 
sodium should be about 20 to 30 grains (1.3-2) three or four times a 
day. It is also thought that this mixture protects the heart, whereas 
the salicylate when given alone fails to do so. 

Acetanilid does good by benumbing the sensibility of the patient 
to the excruciating pain consequent upon movement, and so putting- 
aside the nervous wear and tear of sleeplessness and suffering. 
Further than this, it would seem probable that acetanilid possesses 
a direct antirheumatic influence. The author has found that ace- 
tanilid in such cases will often relieve the pain, and so permit a 
refreshing sleep, in doses of from 4 to 8 grains (0.25-0.5) three times 
a day, and that these amounts do not cause the excessive sweating 
which the necessarily large doses of salicylate sometimes produce 
sweats which leave the patient oftentimes almost dyspneic from 
very weakness. Whether this temporary relief produces such 
changes in the system as to permit of a better battle against the 
disease, or whether it actually counteracts the rheumatic poison, 
we do not know. 

The following prescription, which is of additional value because 
the caffeine supports the heart and increases urinary secretion, 
may be employed: 

1$ — Acetanilidi gr. xl (2.6) 

Caffeinae gr. xx (1.3) 

Camphorae monobromatis gr. xx (1.3). — M. 

Fiat in capsulas vel pilulse No. xx. 

S. — One every three hours or three times a day. 

Phenacetin is often very useful when used in rheumatism for 
the relief of pain, particularly if combined with phenyl salicylate 
(salol) . 

In some cases there can be no doubt that rheumatism phylacogen 
is specific in its effects. (See Phylacogens, Part II.) 

The other drugs used in acute rheumatism are numerous, but only 
a few of them deserve attention here. There is abundant evidence 
on record that full doses (10 to 30 minims [0.6-2.0]) of the fluid- 
extract of cimicifuga if given every five hours will decrease the 
redness and pain of the joints and shorten the attack in some cases. 

A large number of drugs are used in subacute or chronic rheu- 
matism. Of these the chief is the iodide of potassium, followed by 



918 DISEASES 

the acetate, bicarbonate, and citrate of potassium. If the iodide is 
used, the following prescription is of service: 

I^ — Potassii iodidi g j (30.0) 

Syrupi sarsaparillse compositi f5vj (180.0). — M. 

S. — Dessertspoonful (8.0) three times a day, after meals. 

In other cases it is best, because of the disagreeable taste of the 
iodide, to give it in sugar-coated pill or in tablet form, but care 
should be taken that milk or water is taken at the same time to 
prevent gastric irritation. 

Or, if preferred, 10 to 30 grains (1.3-2.0) of the bicarbonate of 
potassium may be taken every four or five hours in water flavored 
with cinnamon for the sake of the taste, or the citrate of potassium, 
which is more agreeable, may be taken in equal amount. If the case 
is very obstinate, sometimes a little colchicum added to the prescrip- 
tion given above may be useful, as follows : 

I}— Potassii iodidi 3 j vel gij (30.0-60.0) 

Vini colchici seminis f 5ss vel f 5j (15.0-30.0) 

Syrupi sarsaparillae compositi q. s. ad fSvj velf5xij (180.0-360.0).— M. 

S. — Dessertspoonful (8.0) three times a day, after meals. 

In all cases of rheumatism the physician should look for septic foci 
in the tonsils, jaws or prostate glands. 

The local remedies in the later stages of rheumatism are chiefly 
counterirritants and sedatives. Thus, small or large blisters applied 
around a stiffened joint after the general systemic excitement has 
passed may be of great value in restoring the suppleness of the 
joint and in aiding in the absorption of the effusion. The remain- 
ing local treatment consists in thoroughly painting the stiffened 
joints with tincture of iodine if blisters are not used, or in the appli- 
cation of vera trine ointment or iodine ointment around the joint. 
(See Veratrina.) Sometimes the application of ichthyol and lanolin 
in equal parts, also rubbing this ointment into the tissues thoroughly, 
will aid in the absorption of inflammatory exudates. 

In this connection we must not forget the great value of morphine 
in endocarditis, myocarditis, and pericarditis; for not only does 
this drug give relief from the pain, but it also diminishes the patient's 
anxiety, quiets his restlessness, and slows the pulse by this means 
and by direct action upon the circulatory system. This question 
of slowing the heart does not receive sufficient attention. When 
we consider that a difference of ten beats a minute amounts to 
600 beats per hour, and to nearly 15,000 beats a day, we can see 
how comparatively slight variations in pulse-rate may mean very 
great variations in the amount of work done by the heart in twenty- 
four hours. For the prevention or relief of endocarditis the appli- 
cation of a number of small blisters over the precordium seems to 
be a very valuable measure; or, in their place, 8 to 12 leeches may 
be placed over the heart and,f olio wed by the application of an ice-bag. 
(See article on Pericarditis.) 



RHEUMATISM 919 

No drugs can serve to protect the heart so well as complete physi- 
cal rest. Xot only is this necessary during the attack, but for 
several weeks afterward; and if the patient gets up too soon, a 
latent, unsuspected valvulitis may gradually develop into a fatal 
lesion. The lame valve must be given time to recover before it is 
given more work to do. This is perhaps the most important thera- 
peutic fact in regard to the therapy of this disease. 



RHEUMATISM (CHRONIC ARTICULAR). 

Chronic rheumatism is one of the most obstinate diseases with 
which we have to deal. In some cases the acute form just consid- 
ered merges slowly into the chronic form, or, in other instances, the 
disease develops gradually, increasing, it may be, by exacerbations 
or by gradual progression. In a large proportion of cases it is usually 
a low grade septic arthritis, in which the joints suffer from a single 
or multiple infection. In other cases the cause is a rheumatic or 
gouty diathesis. (See Vaccine Therapy and Phylacogens.) 

The treatment of chronic rheumatism is somewhat different from 
that of the more acute form, and approaches that of gout in some 
of its therapeutic indications. In other words, the salicylates are 
not so useful in these cases as are the iodides and colchicum, so that 
in the majority of instances the prescription of iodide, sarsaparilla, 
and colchicum given in the article on Acute Rheumatism is indi- 
cated. When anemia or weakness is present, cod-liver oil is often 
of great service, and it is worthy of note that this useful nutritive 
remedy was first brought into therapeutics by the fishwives of 
Holland, who found it useful in the attacks of rheumatism to which 
their husbands were subjected through exposure. 

When the oil is thoroughly rubbed into chronically inflamed joints 
it is almost as useful as when taken internally. 

The same forms of severe counterirritation are not so useful in 
chronic rheumatism as in the subacute form, but a very valuable 
therapeutic measure in these cases is the use of the Russian or Turkish 
bath or an improvised hot bath by means of a lamp and a blanket. 
Baking the affected joint at a high heat is often very useful. 
(See Heat and Cold.) Liniments are always called for, for two 
reasons: first, they relieve pain and do good to the parts, if not 
from their medicinal properties at least by the rubbing which accom- 
panies their application; second, because they give the patient 
something to do or to have done, and therefore impress him with 
the object-lesson that his attendants are attentive and alive to his 
suffering and need of sympathy and care. 

Among the lower classes the belief in liniments is widespread, and 
their use will often instil into the minds of the friends a far greater 
confidence than the most rational of treatments with the liniment 



920 DISEASES 

left out of the list of remedial measures. The following liniments 
will be found useful under these circumstances: 

1$ — Tincturae aconiti f 3vj (24.0) 

Tincturse opii f 5 j (30.0) 

Olei terebinthinse fgj vel fgij (30.0-60.0) 

Linimenti saponis . . . . q. s. ad 5viij (240.0). — M. 

S. — Poison. Use as a liniment three times a day. 

Or, 

B — Aquae ammonias fortioris f 5iv (16.0) 

Olei cajuputi f3j (4.0) 

Tincturse belladonnae foliorum .... fgj vel f§ij (30.0-60.0) 

Linimenti camphorae . . . q. s. ad f5viij (240.0). — M. 

S. — Poison. Use as a liniment. 

Or, 

1$ — Tincturae aconiti f 5j (30.0) 

Tincturse opii, 

Aquae ammoniae aa f 5iv (16.0) 

Linimenti chloroformi f§vj (180.0). — M. 

S. — Poison. Use as a liniment to chronically inflamed muscles or joints. 

In other instances the greatest relief is obtained by employing 
the following ointment: 

^ — Veratrinae gr. xxx (2.0) 

Hydrargyri iodidi flavi 3j (4.0) 

Adipis lanae hydrosi 3ij (60.0). — M. 

S. — Use as an ointment over the joints. 

This ointment ought not to be widely distributed, and the pulse and 
respiration should be watched, as the veratrine may be absorbed 
and depression of a severe character set in. 

For the reduction of enlargements of the joints due to the disease, 
and accompanied in some cases by pain, the following ointment is 
serviceable: 

^ — Unguentiiodi §j (30.0) 

Adipis 3 ivvel §j (15.0-30.0) 

S. — Apply locally. 

Or, still better, 

R— Ichthyolis 3iv to 5J (15.0-30.0) 

Adipis §j (30.0).— M. 

S. — Rub into the joints thoroughly. 

In many cases ichthyol is certainly the most efficient remedy for 
the enlarged and painful joints. (See Feet.) 

The employment of red flannel over the inflamed joints is no 
better than the use of white flannel, and it is never beneficially 
" medicated/' as claimed in the stores. The only advantage of red 
flannel is that, as it is dyed, the wool is often better for not being 
thoroughly bleached, and is in larger amount. The disadvantages of 
red flannel are that if the patient sweats the dye stains the clothing, 
and the possibility of its producing irritation of the skin or even 
systemic effects of an evil character. 



RICKETS 921 

It is important to remember that many cases of " rheumatism" are, 
in reality, due to muscle strains produced by deformity, as disease 
or weakness of the spine or flat-foot, or to infected foci in the tonsils 
jaws or prostate. 

RICKETS. 

Rickets may be defined as a state of the body of an infant or child 
in which there is a deficiency of the normal salts of the bones and 
tissues, with corresponding enlargement of the organic portion of 
the bone, or, in other words, the cartilaginous parts. Generally the 
term is applied solely to designate bony troubles, but every practis- 
ing physician sees cases where the manifestations of rickets are 
emphasized in gastro-intestinal disorders rather than in bony deform- 
ities. The chief cause of rickets in children, aside from the presence 
of any exhausting disease, is inanition; that is, malnutrition of a 
specialized form, or, in other words, bone-salts and vitamine starva- 
tion. This may occur after or before birth, and it is quite common to 
see children, born of mothers ill-fed or whose assimilation of salts is 
defective, with soft bones or a distinct tendency to rickety develop- 
ment. In other cases the condition is chiefly one of failure of 
assimilation rather than of starvation of bone salts. 

The treatment of rickets is therefore largely dietetic and devoted 
to the improvement of the food and digestion. In the presence of 
this disease no part of the body fails in force more than the diges- 
tive apparatus, probably because the character of the blood is 
altered, and partly because the stomach cannot secrete properly- 
formed juices from imperfectly nourished glands. 

The medicines to be used in rickets are general tonics, digestives, 
and stimulants, and bone tonics, such as salts of lime and soda. 
The general tonics are cod-liver oil, quinine, nux vomica, and iron, 
while the digestive tonics are the simple bitters, and syrup of iodide 
of iron. The cod-liver oil supplies the needed vitamines. 

Tonic treatment is best carried out in young children by the 
administration of quinine in the form of euquinine or by the use of 
strychnine in the dose of ^ to y^-g- grain (0.0003-0.0006) in sugar- 
coated pink granules. Arsenic trioxide in the dose of T ^ ¥ grain 
(0.0006) in tablet triturate three times a day is also useful. 

A very useful preparation is the following: 

T$ — Olei morrhuse f3vj (24.0) 

Syrupi calcii lactophosphatis, 

Liquoris calcis aa f5iij (90.0). — M. 

S. — \ to 1 teaspoonful (2.0-4.0) two or three times a day. Shake thoroughly. 

Nux vomica is so bitter as to be difficult of administration to 
young children, and when given only \ to \ minim (0.008-0.015) of 
the tincture should be used, three times a day. 

Where a distinct scrofulous tendency exists and anemia is present, 
small doses of the syrup of the iodide of iron are particularly of ser- 



922 DISEASES 

vice, and \ to 1 minim (0.03-0.08) may be given three or four times 
a day to a child of six months or a year, thus: 

Ifc — Syrupi ferri iodidi . . . . . . . gtt. xij vel xxiv (0.8-1.5) 

Aquse destillatse q. s. ad fgiij (90.0).— M. 

S. — Teaspoonful (4.0) every four or five hours during the day. 

Or, 

]$— Syrupi ferri iodidi gtt. xij vel xxiv (0.8-1.5) 

Syrupi q. s. ad f giij (90.0).— M. 

S.— Teaspoonful (4.0) three times a day, after meals. 

The salts of lime and sodium are of direct benefit to the bones, 
forming by their presence in health a large proportion of the osseous 
system, and therefore they may be considered as foods rather than 
drugs. Very often their administration to nursing mothers or 
pregnant women saves the maternal teeth from caries and preserves 
the general health of the mother and child. The following prescrip- 
tion may be used: 

1$ — Syrupi calcii lactophosphatis fgiv (120.0) 

S. — \ to 1 teaspoonful (2.0-4.0) three times a day, after meals. 

The ventilation of the rooms where a child prone to rickets is 
kept should be excellent, not too hot or cold and free from draughts. 
Sun baths are essential and, as already stated, the greatest dietetic 
care exercised. A cool sponge-bath is useful at night if the patient is 
strong enough, or a good rubbing with salt and whisky, 1 dram (4.0) 
of salt to a pint (480 cc) of whisky, is of still greater service. 

Special attention should be paid to the development of the muscles 
by massage and passive movements, as these parts are always weak. 
Walking must not be allowed too early, as it may cause bony deform- 
ities. (See Vitamines.) 

RINGWORM. 

Many methods of treating this affection are employed and are 
more or less efficacious. Jackson recommends as the best the 
rubbing into the part of 1 dram (4.0) of iodine crystals in 1 ounce 
(30.0) of real goose-grease. This grease has greater penetrating 
power than ordinary fats and usually is effective by the end of three 
weeks, the ointment being applied night and morning until some 
redness of the skin appears, when it is used once a day. Depilation 
is not necessary, for the hair soon falls out, but is supplanted by a 
new growth. This application may burn slightly, but is not really 
painful. 

SCARLET FEVER. 

This disease, the most fatal of all the exanthematous diseases of 
childhood, requires the greatest care in its treatment, but this does 
not mean the free use of drugs. We have no specific remedy and 
can only treat conditions which when they arise threaten danger. 
Complications often arise requiring skill on the part of the attendant, 



SCARLET FEVER 923 

and it is upon his success in treating these outbreaks, as well as in 
the general direction of the case, that the life of the patient may 
depend. 

A milk diet alone or fortified by the use of carbohydrate gruels, 
not broths, partly predigested by taka-diastase should be rigidly 
followed. 

The convulsions which rarely usher in an attack are to be treated 
by the use of the warm pack or hot bath (Part III), and if need be, 
5-grain (0.3) doses of chloral and 10 to 20 grains (0.6-1.3) of bro- 
mide of sodium given by the rectum for a child of five to eight years. 
The convulsions of the advanced stages are often uremic, and must 
be treated accordingly. (See Uremia.) 

From the very beginning of an attack to its end the child should 
always be supplied with plenty of pure water, and, if possible, this 
water should be obtained from a spring containing a low percentage 
of solids, as Poland water, which is widely sold throughout the 
United States. If this is impossible, then Celestins Vichy water may 
be employed unless dropsy is present. The object of this treatment 
is to flush out the kidneys, and to so dilute the toxic substances 
generated in the body, by the fever and the germs of the disease, 
that they lose, to a great extent at least, their poisonous and irritat- 
ing powers. If the child is so young that it takes food from a nurs- 
ing bottle, Poland water may be placed in the bottle. 

In other cases a prescription containing sweet spirit of nitre and 
citrate of potassium proves useful, as follows: 

1$ — Spiritus setheris nitrosi . f §j (30.0) 

Potassii citratis 5ij (8.0) 

Aquae destillatse q. s. ad . fgvj (180.0).— M. 

S. — Teaspoonful (4.0) every two hours if the urine is highly acid. 

Scanty urinary flow due to vomiting and deprivation of fluid 
should be treated by the use of the rectal drip (see Peritonitis), 
but the free use of water by the mouth or drip is to be avoided if 
anasarca is threatened or already developed. The use of daily hot 
packs is also useful to relieve the kidneys of congestion and quiet 
nervous irritability. Occasionally dry cups over the kidneys do good. 

The further treatment of the disease rests upon the symptoms 
alone. We cannot cure the patient by the use of remedies, but we 
can do much toward making the pathway to health smooth and 
free from pitfalls and obstructions. 

Probably the most common complications calling for treatment 
when the kidneys have been treated in the way just spoken of, are 
high temperature or fever, and sore-throat or angina. The fever 
is to be controlled in these cases in precisely • the same way that it 
is in all other conditions in which it is present. It is best to attempt 
to keep it below 102° F., by tepid sponging, which also allays the 
itching of the skin, or, if the temperature continues to rise, by the 
use of cold water. Generally the popular fear that the application 



924 DISEASES 

of cold to the surface will drive the eruption "inward" is so strong 
as to make the cold sponging objectionable to the friends; but if 
the temperature reaches 105° F., the physician must assert the fallacy 
of this belief and insist on its use. (See Cold, Part III.) When 
the patient is overcome by toxemia, the skin marbled and mottled, 
and the brain stuporous, he should be placed in a bath at 100° F., 
and water at 60° or 70° F. poured on his head and shoulders with 
some force or the wet pack may be used. In very young children 
the same effect may be obtained by dipping the patient alternately 
in hot and cool water. The object is to cause reaction and equalize 
the circulation. If suppression of the rash occurs, the wet pack 
must be used. (See Heat, Part III.) Where the head seems to 
be particularly hot and the fever is high an ice-bag or a head-coil 
of rubber tubing is to be employed, and through the latter water may 
be circulated at whatever temperature is thought best. (See Cold, 
Part III.) 

The treatment of the sore-throat of scarlet fever is an important 
part of the care of the child in many cases. Small pellets of ice may 
be held in the mouth and an ice-bag applied to the outside of the 
throat. This is done by finely breaking some ice and placing it in 
a thin India-rubber bag about the neck, the surface of the bag being 
covered by a cloth to prevent too rapid melting of the ice and the 
wetting of the clothes by the condensation of moisture on the surface 
of the bag. This treatment may be used during the entire attack 
if needed, and the contents of the bag renewed as often as the water 
becomes at all warm from the heat of the body. By this means the 
redness of the fauces and the swelling of the glands of the neck are 
relieved. Chlorate of potassium may be used in a spray or on a 
swab, but never internally owing to its irritant effects upon the 
kidneys and stomach and its general influence on the blood. When 
a false membrane forms, antidiphtheritic serum is to be given until 
a bacteriological examination shows that it is not due to the Klebs- 
Loeffler bacillus. This membrane should be locally treated by 
applying peroxide of hydrogen. 

In cases where the eruption suddenly fades or is never well devel- 
oped it is of the greatest importance that it be made active. Under 
these circumstances the child may be placed in the warm wet pack, 
and, if the head is very hot, cold applied to the vertex and throat 
while the body is enveloped in the blanket. (See Heat.) This 
often brings out in an hour or two a bright scarlet rash, and the 
child falls asleep and wakes up free from delirium and high fever. 

The itching and burning of the skin in many cases of scarlet fever 
are annoying symptoms, and they may become really dangerous. 
Fever of high degree can be brought on solely through nervous 
irritation, thus explaining a fact long well known to clinicians— 
namely, that the relief of this dermal irritation in scarlet fever may 
be followed by a fall of temperature. To relieve this symptom it 
will often be found advisable to cover the entire skin with a thin 



SCIATICA 925 

layer of benzoated lard. Oftentimes a warm pack will relieve 
this symptom. In other cases almond oil should be used. 

If nephritis comes on and in a severe form, the greatest care is 
necessary, and the object of the physician must be to make the 
skin, disabled as it is, carry out sufficiently an active eliminative 
function to relieve the kidneys of strain. It is well to aid in the 
removal of effete matter by producing catharsis. Sweating may 
also be produced by the employment of heat obtained by the use of 
the hot pack or the mustard pack. (See Heat.) The thermometer 
must be placed in the mouth to foretell any danger from heat-stroke 
if the sweat should fail to appear. 

The after-treatment of scarlet fever during convalescence, if treat- 
ment is needed, consists in the use of Basham's mixture or the tinct- 
ure of the chloride of iron, and in the employment of simple bitters, 
strychnine, or quinine. Fresh air, sea air, or mountain air is useful, 
while cold or exposure to cold air or draughts is to be carefully 
guarded against. 

The view has been that the desquamated skin is the active factor 
in distributing the infection. If this be true it can be controlled by 
the use of oil inunctions and quarantine. The nasopharyngeal dis- 
charges are the chief agents in spreading infection, and these passages 
should be sprayed daily with normal salt solution and then dropping 
a 10 per cent, solution of argyrol into the nostrils, followed by a 
few drops of liquid albolene. 



SCIATICA. 

Sciatica is an exceedingly obstinate affection, in many cases 
resisting the best treatment for weeks. It seems to be due to rheu- 
matic tendency in the majority of instances. In other instances it 
is due to injury or jarring of the nerve, as by heavy persons stepping 
off from a high step to the hard ground. Thus the most obstinate 
case ever seen by the writer was one in which a man weighing about 
two hundred and fifty pounds acted as "coupler" on a switching 
engine, and, though wonderfully agile for his weight, provoked the 
disease in the leg on which he always first struck the ground when 
jumping from the platform of the moving locomotive. 

The treatment for all cases is both internal and external. The 
internal treatment may be the same as that already described under 
Acute or Chronic Rheumatism, or in other instances consists in 
the use of large doses of bitartrate or citrate of potassium, 40 grains 
(2.6) three times a day, in plenty of water to aid in the maintenance 
of free kidney action. If the pain is excessive, morphine should be 
given, or aspirin, antipyrine, or acetanilid may be used. In some 
instances methylene blue in 5-grain (0.3) doses twice or thrice a 
day has seemed to relieve pain. (See Methylene Blue.) 



926 DISEASES 

- The local treatment of sciatica is quite various. The daily use of 
an ether or rhigolene spray over the part may be resorted to. 

In acute cases, from three to five large wet or dry cups, preferably 
the wet, may be placed along the course of the sciatic nerve with 
great advantage. In many cases absolute rest of the limb, obtained 
by placing it in splints, has to be adhered to before cure is possible. 
In other instances the nerve should be exposed and any adhesions 
broken up. Hot- water bags should be placed continually about the 
exit of the sciatic nerve from the pelvis. 

The liniments recommended in chronic rheumatism may be tried, 
and cod-liver oil is of service in some obstinate cases. 

It is to be recalled that so-called sciatica is often due to sacro- 
iliac strain or hip-disease. 

SCLERITIS. 

(See Episcleritis.) 



SCROFULOSIS. 

It is now universally recognized that scrbfulosis is really a form 
of tuberculosis, yet, as its manifestations are often quite distinct, 
it is separately considered. 

Scrofulosis is to be treated by hygienic measures rather than 
drugs, by fresh air, residence by the seaside, proper out-door exercise, 
massage, and dietetics, all of which take precedence of medicines. 

If these necessary adjuncts to a cure are obtainable, the prognosis 
is fair, to say the least, and the following drugs may be used, all of 
them being devoted to the improvement of the general health, and 
not to any direct influence over the scrofulous tendency in itself. 
It is hardly necessary to state that cod-liver oil is perhaps the best 
remedy of all. The oil should be given in emulsion, being first pan- 
creatized and so prepared as to be somewhat palatable by the addi- 
tion of flavoring substances if the child is old enough to appreciate 
such flavors. In young children, while distaste of the oil is often 
shown at first, a liking for it rapidly develops, so that the writer 
has seen children cry for it when the oil was discontinued. When 
anemia is present, syrup of the iodide of iron is useful in from 1- to 
10-minim (0.05-0.6) doses, according to the age of the child, as 
follows : 

R— Syrupi ferri iodidi f3ss vel" f3j (20-8.0) 

Aquae destillatae . . . . . . q. s. ad fgiij (90.0). — M. 

S. — Teaspoonful (4.0) in water three times a day, after meals, to a child of one year. 

In place of iodide of iron, T ^ T grain (0.0006) of arsenic trioxide 
or T -J~Q grain (0.0006) of corrosive sublimate may be given to a child 



SCURVY 927 

of three or four years, in the form of tablet triturates, or the following 
prescriptions may be used: 

1$ — Liquoris potassii arsenitis Tfl.xvj (1.0) 

Aquae destillatae fgij (60.0).— M. 

S. — Teaspoonful (4.0) three times a day, after food for a child of five years. 

Or, 

1$ — Hydrargyri chloridi corrosivi .... gr. y 1 ^ vel gr. -i- (0.006-0.12) 

Aquae destillatae fgij (60.0).— M. 

S. — Teaspoonful (4.0) every five hours, after food. 

The use of iodides is generally contraindicated in those cases in 
which softening and breaking down of the glands . are going on 
rapidly. In their place calx sulphurata may be employed, by 
placing 1 grain (0.06) of it in half a tumblerful of water and giving 
a teaspoonful hourly. The mixture should be freshly made every 
day, to prevent its becoming oxidized. 

When enlargement of the cervical glands takes place, iodine 
ointment, diluted, one-half of lard, should be well rubbed into the 
part twice daily, but it should be stopped at once if signs of softening 
or fluctuation appear or if the skin becomes reddened. In cases in 
which these enlargements are persistent, ichthyol ointment is to be 
rubbed in, using the following formula: 

3— Ichthyolis 3ij vel 3hj (8.0-12.0) 

Adipis "..... gj (30.0).— M. 

S. — Apply locally. 

If this is not followed by cure, the glands should be excised and 
the cavity packed with iodoform, as in the majority of cases these 
enlargements will be found to be distinctly tuberculous. (See 
Adenitis.) 

SCURVY. 

The cure of this state is so completely dependent upon the use of 
proper foods that almost no drugs are to be employed in its treat- 
ment. 

The only remedies particularly indicated are orange- or lemon- 
juice or lime-juice and tomato -juice. Beef -juice is also valuable. 
Arsenic and iron are of service in most cases, and rest and quiet 
are to be insisted upon. 

By far the more common form of scurvy is seen in bottle-fed 
babies. The child may or may not have rhachitic manifestations. 
Generally it loses animation, becomes listless and peevish, evidently 
suffers pain in its body and limbs when it is lifted from the bed, and 
looks feeble and wan. The gums become spongy and swollen, and 
have an ecchymotic appearance, and light blows produce bruises 
out of proportion to the severity of the injury. The treatment of 
infantile scurvy is a complete rearrangement of the child's diet-list, 
and varying its food. No one baby food should be used to the 
exclusion of another, and sterilized milk is to be supplanted, if possible, 



928 DISEASES' 

by fresh new milk. It is important to remember that a large pro- 
portion of these occur in the children of the rich, who have subsisted 
largely on prepared "Infant Foods." (See Vitamines). 

SHOCK. 

The term shock is applied to a state in which the patient is in 
collapse as to his circulation and nervous energy. It is to be dis- 
tinctly separated from syncope in which unconsciousness is present. 
The patient is often seemingly benumbed as to his mentality and 
may be profoundly apathetic, although, if spoken to, it is found 
that his intelligence is preserved even if he be so feeble that he does 
not speak in reply. It is unfortunate that very different states 
are described under this term and it is practically certain that the 
symptoms, although they may be similar in different persons, are 
nevertheless due to different causes and often to varying quantities 
of each cause. In other words, the cause of the condition is com- 
plex, not simple. All attempts to prove that shock is produced as 
the result of a single factor have failed. It is not possible in this 
space to deal with all the different theories as to cause but only 
with the dominant conditions present and what can be done for their 
relief. These dominant conditions are a marked fall in blood-pres- 
sure and a tendency to arrest of heat production and an increase 
of heat dissipation. The fall of blood-pressure is to be combated 
by the use of atropine given in full dose intramuscularly, since 
atropine tends to restore circulatory equilibrium by contracting the 
bloodvessels in the splanchnic area and dilating the peripheral 
vessels. The use .of normal saline intravenously is of little value 
because the vessels dilate as fast as the fluid flows in and unless the 
fluid is hypertonic it may transude into the tissues. (See Intra- 
venous Injections, Part III.) To prevent this not only is a hyper- 
tonic solution useful, say one of 1.0 instead of 0.9, but its transla- 
ting properties may be arrested by the addition of sterile gum acacia, 
6 per cent. (See Intravenous Injections.) A transfusion with whole 
blood is better still if hemorrhage has been a factor. The patient 
should not be put flat but rather be placed in the Fowler position 
and should not be oppressed by being buried in soft pillows. Strych- 
nine and particularly caffeine should be given intramuscularly in some 
cases in full dose. These drugs if used before exposure to the cause of 
shock may make the body unduly susceptible to it, but after the insult 
the caffeine in doses of 3 to 6 grains rouses the nervous activities of the 
patient and calls in his reserve energies. The use of alkaline injections 
to combat so-called acidosis, while advocated by some observers, 
has not proved efficient and it has not been proved that acidosis is 
the cause of the symptoms or that the acidosis said to be present 
is sufficiently severe to produce them. Porter has urged the use 
of C0 2 inhalations on the basis that by increasing the amount of 



SMALLPOX 929 

that gas in the blood the dominant vasomotor center is stimulated 
to greater effort to raise pressure, and there are good physiological 
reasons, as well as clinical results, to support this view, but it has 
not proved useful. The greater amplitude of thoracic movement 
under such inhalations also tends to pump the blood from the great 
venous trunks into the heart. We are too prone to forget the import- 
ance of respiratory movement as a circulatory factor. The greatest 
care should be taken that the patient is moved about as little as 
possible, that he have absolute quiet, and above all things that he 
be not exposed to cold. External heat should be applied to the 
extremities, but not so as to oppress him as it often does if his chest 
is packed about with hot-water bags. Hot normal saline may be 
given by means of the Murphy drip. (See Peritonitis.) If the 
heart flags some preparation of digitalis suitable for hypodermic use 
should be given in full dose intramuscularly, but the rapid or feeble 
pulse is more the result of low blood-pressure than of actual cardiac 
weakness. (For the use of adrenalin and pituitrin in vascular col- 
lapse, see Suprarenal Gland and Pituitary in Part II.) 

SMALLPOX. 

The treatment of smallpox is not specific, simply because it is 
one of those diseases which run a given course and which cannot 
be aborted. We can only treat the various symptoms which present 
themselves, and by the modification of these manifestations prevent 
complications and sequelae to some extent. The fever is to be 
treated as is any fever of this class. Often it can be allayed by a 
mixture containing, spirit of nitre, and spirit of Mindererus (liquor 
ammonii acetatis), while the headache or backache may be con- 
trolled by small doses of antipyrine or acetanilid. Mustard 
plasters are not to be used for the backache, as the dermal irri- 
tation will increase the eruption. Insomnia and restlessness, if 
excessive, are to be quieted by the bromides or chloral, care being 
taken that the doses of the latter are not large enough to depress 
the heart. It must be remembered that the time of onset of the 
secondary fever, the eighth day, is one of grave import to the patient. 
More patients die from this secondary septic infection than from the 
disease itself. Before its arrival the treatment of the case must be 
so managed that strength is saved for this strain, and tincture of 
the chloride of iron, in 5- to 10- (0.3-0.6) or even 20-minim (1.3) 
doses, may be resorted to to give strength to the patient and to help 
control the pyemic fever. The pulse should be watched, and if it 
flags, brandy and whisky should be freely but wisely used. At the 
same time nourishment in the shape of eggnog, milk punch, and 
rice and barley gruels should be given as freely as the digestion will 
allow. 

The peripheral irritation and itching of the eruption are a cause 
59 



930 DISEASES 

of the fever in part, and produce much unrest and nervous irritability. 
The condition of the skin is therefore to be looked after and pitting 
prevented, if possible, by every means in our power, particular care 
being taken to prevent its development on the face. One of the 
means which has been recommended to prevent pitting is the use 
of flexible collodion, and another application is glycerite of starch 
or simple cerate applied in a heavy coating. Some physicians 
recommend inserting the tip of a nitrate of silver stick into each 
vesicle as it ruptures, to prevent pitting. All of these measures 
are futile in most cases and the use of collodion is probably harmful 
in some instances. The best application to use is made of 4 parts 
of salicylic acid to 100 parts of vaseline or cold cream. Sometimes 
anointing large areas of the body with sweet oil slightly phenolized 
(1:100) is useful to check irritation. 

If the mouth is sore, a mouth-wash of chlorate of potassium and 
water may be used, flavored with a little tincture of myrrh. (See 
Chlorate of Potassium and Stomatitis.) 

Disinfection, good ventilation, and the avoidance of much light 
are necessary. 

STINGS AND BITES. 

The stings of nearly all small insects depend for their activity 
upon formic acid, and are to be relieved by the use of dilute alkaline 
liquids, or, better still, by the application of ammonia, or, instead, 
an application of ordinary or flexible collodion may be made, or, if 
preferred, salicylic acid may be added in the proportion of 5 grains 
to the ounce (0.3-30.0), which is improved in its action by the addi- 
tion of 1 part of mercury bichloride to 1000 of the collodion, or 
water of witch-hazel may be applied. Sometimes a solution of 
phenol, 1:100 or 1:50, when sponged over the parts exposed, not 
only relieves the itching of mosquito-bites, but also repels the mos- 
quitoes. In other instances the stings are relieved and cooled by the 
use of dilute or pure vinegar. 

A useful application to prevent mosquitoes from biting is: 

3— Olei citronellse f 3 j (4.0) 

Alcoholis f 5J (4.0).— M. 

S. — Apply freely to the skin exposed. 

In snake-bite the best treatment consists in sucking the wound, 
as snake-venom, even if swallowed, is not poisonous. The part 
should then be freely incised, so as to cause the blood to flow freely, 
and immediately the wound should be filled with permanganate of 
potassium, and full doses of this drug given hypodermically about 
the wound, the salt being diluted three-fourths with water, and 
followed by full doses of ammonia given by the mouth. The secret 
of successful treatment consists, however, in the use of a ligature 
above the bitten spots and the opening of the wound as soon after 



STOMATITIS 931 

its reception as possible, thereby preventing absorption of the 
poison. Antivenine and other antitoxins promise much for treat- 
ment in the future. 

STOMATITIS. 

This annoying affection is most commonly seen in children, and 
is characterized by the appearance on the tip and sides of the tongue, 
lips, and lining membrane of the mouth of small spots which some- 
times have a reddened zone around them, and which result in minute 
or large ulcers. 

The best treatment, if the kidneys are not acutely inflamed, is the 
use of the following prescription, which largely depends for its value 
upon the potassium salt used: 

1$ — Potassii chloratis . . 5j (4.0) 

Tincturae myrrhae gtt. xx (1.3) 

Elixiris calisayae fgiij (90.0).— M. 

S. — Teaspoonful in water every four hours. 

As the chlorate of potassium is eliminated with the saliva, it not only 
does good when taken into the mouth, but is also active all the time 
that it is being eliminated. If the stomach is disordered, the same 
preparation may be used as a mouth-wash. Often constipation is 
present, and it should be relieved by salines or by rhubarb in the 
form of the aromatic syrup. Another remedy which is very efficient 
in stomatitis is borax, used as a mouth- wash, in the strength of 10 
to 15 grains to 1 ounce (0.6-1.0:30.0) of water and honey, as follows: 

1$ — Sodii boratis gr. xxx (2.0) 

Mellis depurati f3iij (12.0) 

Aquae destillatse q. s. ad fgiij (90.0). — M. 

S. — To be used on a swab or as a mouth-wash every four hours. 

This also may be given internally to adults in the dose of a tea- 
spoonful (4.0) every three hours. 

In many cases peroxide of hydrogen in the proportion of 1 ounce 
(30.0) to 8 ounces (240.0) of water proves a valuable mouth-wash. 

When stomatitis is associated with pyorrhea alveolaris the following 
is useful: 

1$ — Acidi salicylici, 

Acidi benzoici ' aa gr.xv (1.0) 

Tincturae krameriae f 5iss (6.0) 

Alcohol, absoluti fgj (30.0).— M. 

S. — Teaspoonful to a small wineglassful of water as a mouth wash. 

If the liver is at fault and is torpid, nitrohydrochloric acid is useful 
When the spots do not readily yield to treatment they may be 
touched with the tip of a stick of silver nitrate, which treatment, 
while it is momentarily painful, is very efficacious. 

Nearly always with this disease in childhood there is considerable 
fever, vomiting, and wakefulness at night, with fretfulness and 
crying during the day, and total refusal of food, not because hunger 



932 DISEASES 

is absent, but because the food hurts the mouth and is rejected 
with a cry of pain as soon as it touches the lips. The food should 
be very soft milk-toast for older children, or milk with lime-water in 
it in large amount for infants fed by the bottle. If a child at the 
breast be attacked, the mother's nipple should be carefully washed 
with boric-acid solution after each nursing. A warm foot-bath at 
night is often necessary to produce rest, and 10 minims (0.6) of 
sweet spirit of nitre thoroughly diluted may be given with advantage 
to a child of one or two years. If the irritability of the nervous 
system is excessive, bromide of sodium or strontium in the dose 
of from 1 to 10 grains (0.06-0.6), according to age, three times a 
day, is of service, and may be added to the mixtures already named, 
or, better still, given alone, well diluted with syrup and water. 

After the attack tonics and a carefully selected diet are generally 
necessary. 

STYES. 

Styes consist in a localized inflammation of one of the glands in 
the margin of the lid or the surrounding connective tissue. Pain 
may be alleviated with frequently changed hot compresses (water 
110° F.). Abortive treatment has been recommended and practised 
by massaging the swelling with a salve of the yellow oxide of mercury 
(2 grains to 5j> or by painting the surface with an ethereal solution 
of collodion, but such measures are of little avail, and an incision 
into the tumefied area to liberate the pus is promptly indicated. 
Associated conjunctivitis requires a boric-acid solution for its relief. 
It should be remembered that styes indicate ill health; they often 
occur with anemic conditions in young women with menstrual dis- 
turbance. They most frequently appear in the subjects of refractive 
error, hence suitable glasses are required. When they tend to recur 
in crops the internal use of sulphurated lime has been recommended. 

In stubborn cases treatment with autogenous bacterial vaccines 
achieves excellent results. 

SUNSTROKE. 

Sunstroke— or, more correctly speaking, heat-stroke— is an affec- 
tion produced by exposure of the body to any form of high tempera- 
ture, whether the source of heat be the sun, a furnace, or the radiation 
of heat from the earth. For this reason the condition may occur as 
readily at midnight as at mid-day. 

Heat-stroke is to be divided into two classes, in one of which 
excessive exposure to heat upsets the balance of the thermal mecha- 
nism of the body, so that fever (thermic fever) comes on; in the other 
the temperature is lowered and forms the condition known as heat- 
exhaustion. 

The condition of thermic fever is very frequently seen, while 
heat-exhaustion is rare. 



SUNSTROKE 933 

The treatment of these two states is, of course, radically different. 
When a patient has thermic fever and comes under the care of the 
physician, the first thing to be done is to loosen the clothing— if 
possible, remove it — and if the pulse be bounding, the face cyanotic, 
and the heart laboring, to bleed him freely. At the same time 
intra venous injection of normal salt solution should be freely resorted 
to, and this is particularly needful if the blood flows slowly and is 
very dark in hue. (See Intravenous Injection.) At the same time 
cold should be applied to the body, and particularly to the head, 
abdomen, back, and chest. The man should be stripped, laid upon 
a bed, which must be covered with a rubber blanket, and ice-water 
applied to the body by means of a sponge, or a piece of ice may be 
laid on the head, while another piece is rubbed over the rest of the 
body. While this is being done the surface of the patient's body 
must be thoroughly and briskly nibbed in order to bring the hot blood 
to the cooled skin. The cold applications are to be applied chiefly 
to the great muscles of the back. 

Care should be taken that the temperature, when it once begins 
to fall, does not drop suddenly below the normal and cause collapse. 
If the clinical thermometer in the mouth or rectum shows that the 
temperature has fallen to 101.5° or 100° F., the cold application 
should be stopped, and the patient allowed to lie on a bed, covered 
only with a thin sheet. The bodily temperature must be constantly 
watched, as it will probably bound up again in a few minutes, and 
require the application of more cold, used with the same care. This 
second rise is due either to the disorder of the nervous mechanism of 
heat-production and dissipation, or to the fact that, while the surface 
of the body is cooled by the ice, the innermost viscera are still in high 
fever and rapidly heat the surface as soon as the ice is taken away. 
Antipyretics have been found to be almost useless in the hyperpyrexia 
of sunstroke, and are not to be relied upon. 

After the fever has been reduced permanently the danger is not 
all passed, and it is the greatest mistake to discharge a patient as 
cured at this time. After two or three days it is very common for 
a meningitis to develop, accompanied, it may be, by little or no 
fever, but characterized by violent darting headache, which is made 
worse on lying down or on sudden movement. The treatment of 
this state must be bold, and venesection is the only safe method of 
obtaining relief, although vascular sedatives, such as veratrum, may 
be employed. The bleeding should be copious enough to impress 
the circulatory system to some degree, and may be done by opening 
any of the prominent veins in the arm. (See Venesection.) Some- 
times a violent attack of epistaxis saves the man's life when it would 
have been lost through the ignorance of his attendant. If life is 
preserved without vascular depletion, secondary changes in the 
brain may ensue and produce hemianopsia, optic atrophy, imbecility, 
or insanity. Quinine, salicylic acid, and similar substances are all 



934 DISEASES 

contraindicated under these circumstances, because of the conges- 
tion of the meninges to which they predispose by their physiological 
effects. 

The treatment of heat-exhaustion consists in the use of heat instead 
of cold, in order to restore the bodily temperature. Just here, 
however, must be uttered a word of warning— namely, that the 
mere fact that the skin is cold does not prove the case to be one of 
heat-exhaustion, since a rectal thermometer may show the central 
or real temperature of the body to be that of hyperpyrexia. Of 
course, such a case should not receive hot, but cold, rectal injections 
if the symptoms require it. 

The bodily heat in heat-exhaustion is to be raised by placing 
the patient in a bath at 105° to 110° F., or by the use of hot bricks 
or bottles, care being taken that they do not burn the patient. 
The bodily temperature should also be watched, lest the other extreme 
of heat be reached. Atropine should be deeply injected into one of 
the great muscles. 

Cases of heat-exhaustion are not so apt to have meningitis as are 
cases of sunstroke, but they are generally slow to convalesce, and 
require tonics and careful watching for a long time. Indeed, in 
many instances the system seems to receive a shock from which it 
takes several weeks- or months to recover. 



SYPHILIS. 

An indolent sore, which appears without immediate and adequate 
preceding cause, persists for days and weeks, gradually growing 
larger and harder, and which is accompanied within seven days from 
its appearance by hardening and enlargement of the anatomically 
associated lymph nodes is usually a chancre. If the spirochetes are 
found it is surely so, and almost as surely if it disappears in a few 
days under specific treatment. The Wassermann test' is negative 
for the first three or four weeks following the appearance of a chancre. 

When chancroid and syphilis are inoculated at the same time and 
in the same place, a positive Wassermann in the fourth week will be 
indicated. Often such mixed infection is not suspected till secondaries 
develop. 

The diagnosis of secondary syphilis is based on the history of a 
primary lesion; the typical skin manifestations, characterized by 
symmetry of distribution, polymorphism, coppery color, and absence 
of itching; the mucous membrane lesions are characterized mainly 
by the circumstance that nothing else can logically account for 
them; a positive Wassermann test, nearly always present, and the 
prompt curative effect of appropriate treatment. 

The diagnosis of tertiary syphilis is dependent upon the history; 
at times, and scars of previous lesions. As a rule, also upon the 



SYPHILIS 935 

absence of other adequate cause for the symptoms present; at times, 
by the strikingly prompt and beneficial results of specific treatment. 
There is a positive Wassermann test in something more than 60 per 
cent, of these cases. A negative Wassermann test is, therefore, of no 
diagnostic value. 

Maternal syphilis usually gives no characteristic symptoms other 
than ill health otherwise inexplicable, and often a history of mis- 
carriages without adequate cause. A positive Wassermann test 
proves the presence of syphilis ; a negative reaction . has not the con- 
trary meaning. 

Hereditary syphilis exhibits mucous membrane and skin lesions 
fairly characteristic of the secondary stage; or, skipping these, there 
may be in childhood, puberty, or adult life, eye, bone, cardiovascular 
or cerebrospinal lesions, or lowered resistance and impaired vitality — 
none of them characteristic of the underlying condition. The Was- 
sermann test is not largely helpful, being positive in about 50 per 
cent, of the cases; nor are the patients always benefited by specific 
treatment. 

Cerebrospinal syphilis exhibits as its most constant symptoms 
persistent headache, dizziness, and epileptiform convulsions. Treat- 
ment should begin with mercury— arsenic being used with caution. 

In ataxia, paresis, and arteriosclerosis, the administration of 
arsenic may be helpful but must be carefully guarded. 

The most important single element in the treatment of syphilis 
is the maintenance of the patient's vital resistance at its highest point. 
This implies regular exercise, regular bowel movements, moderate 
eating, and the avoidance of all excesses or strains. The teeth should 
be put in order and kept clean. The patient's urine should be 
examined, his weight taken, and his cardio-vascular reserve estimated. 

The proper treatment is that which passes as much arsenic and 
mercury through the patient's body as he can take compatible with 
eating well, sleeping well, feeling well, not being tired, and holding 
to normal weight. 

The drugs used are arsenic, mercury, and, in the later stages, at 
times, potassium iodide. 

Arsenic by intravenous injection is given in the form of arsphena- 
mine or neoarsphenamine— under which general headings are classed 
a variety of preparations, such as Diarsenol, Arsenobenzol (Derma- 
tologic) and the neo forms of these drugs. 

Mercury is given (metallic mercury or calomel) by inunction; 
hypodermic injection (bichloride or salicylate); vaporization (calo- 
mel) ; or mouth administration (protiodide, biniodide, mercury with 
chalk). 

Potassium iodide is of minor import, and not to be used in either 
the primary or secondary stage— is given in the form of an aqueous 
saturated solution, the required number of drops being added to milk, 
of which at least a half glass is used to dilute each dose. 



936 DISEASES 

Arsphenamine is most efficient in the primary and secondary 
Stages. Mercury is efficient in all stages. 

Arsphenamine given intravenously implies both immediate and 
remote risk. The immediate risk is that incident to anaphylactoid 
shock, simulating as it does the phenomena incident to the injection 
of foreign proteins, and characterized by flushing of the face, metallic 
taste, nausea and vomiting, cough, heart hurry, distress in breathing, 
cyanosis, syncope developing rapidly. Arsenical injections should 
be given slowly, since if these symptoms are observed promptly, and 
if the injection be stopped before a large dose is given, and adrenalin 
chloride (10 to 20 minims of a 1 : 1000 solution) be injected intra- 
muscularly a favorable reaction takes place usually within a short 
time. 

The delayed symptoms of an over-dose of arsphenamine are loss 
of initiative, strength, weight, and appetite; often headache; at times, 
dermatitis; appearance of bile or blood in the urine and even the 
development of jaundice. 

Hemorrhagic encephalitis incident to the treatment of cerebro- 
spinal syphilis by arsphenamine without a preliminary course of 
mercury, beginning two or three days after the administration of the 
drug, may be inaugurated by mental confusion and dull headache, 
followed by convulsions, coma, and death. 

To avoid this, in the treatment of cerebrospinal syphilis a course of 
mercury is indicated before the use of the arsenic preparations. 

The earliest manifestation of renal injury incident to arsphenamine 
is polyuria without either albumen or casts, followed later by anuria. 
Renal hypersecretion suggests a temporary stopping of the drug or a 
lessening of the dose. 

Arsenic should be used cautiously in conditions of depressed 
vitality or in the presence of cardio-vascular lesions (including 
aneurism) with failing compensation, hemophilia, advanced, nephritis, 
diabetes, tuberculosis or visceral lesions not luetic. 

Mercury given in an overdose causes gingivitis— this being preceded 
by metallic taste and an offensive odor of the breath; casts and 
albumin in the urine— mercury being an epithelial poison; colicky 
pains and diarrhea, the stools even containing blood. 

Offensive breath and metallic taste, usually the first signs of mer- 
curialization, indicate the prompt stoppage of the drug. 

Chronic mercurial poisoning is manifested by languor, despondency, 
failure of appetite, loss of initiative, and a steady loss of weight. 
This may occur without any gum, urinary or bowel symptoms and is 
an indication for stopping the drug. 

The patient properly treated should feel better and not worse, 
should gain weight and not lose it. 

During the course of treatment, the urine should be examined every 
two weeks; and the weight taken, recorded, and compared at least 
once a month. 



SYPHILIS 937 

Treatment is begun when spirochetes are present; when the Wasser- 
marin test is positive, or when the clinical signs are convincing. 

The prospect of cure is in direct proportion to the timeliness and 
thoroughness of treatment. 

Eight doses of arsph en amine or neoarsphenamine given at intervals 
of five days, constitute the first course. The average dose of arsphe- 
namine is 0.3. 

This treatment is supplemented by mercury, preferably by inunc- 
tion, 1 dram unguent hydrargyri, or 2 drams of calomel ointment- 
being rubbed into the skin every day for six days. This followed by 
a rest period of from three to six days; six of these courses are given. 

At the end of this course of arsenic and mercury, if the patient feels 
well and is without symptoms, a rest of one month is given, without 
treatment; then a Wassermann test is taken and regardless of whether 
this be positive or negative, a second course similar to that already 
indicated is administered. 

Hypodermic injections of mercurial preparations are the fashion 
of the day. The preparation of choice may be either soluble or 
insoluble. Soluble preparations are rapidly absorbed; hence give 
prompt effect. They must be repeated frequently— every day or 
every other day until the indicated course is completed. 

Bichloride, 1 per cent., dissolved in 0.6 sodium chloride solution 
may be used. The resulting mixture should be perfectly clear; the 
daily dose is from J to | grain (0.01-0.02) driven well into the muscles. 
Six such injections are given followed by three days rest. 

Salicylate of mercury is the most approved of the insoluble prepara- 
tions. The average dose is 10 minims in a 10 per cent, goose grease 
suspension, repeated at intervals of from three to seven days. Six to 
twelve doses constitute a course. 

If neither inunctions nor hypodermic injections be applicable, 
mercury may be given by the mouth. Protiodide or other similar 
preparation, \ grain after each meal, with two days rest in seven. 
This dose is cautiously increased and should be continued through- 
out the course of the arsenical treatment— or following it. After 
a month's rest following the first course of treatment a second course 
should be given. 

After the second course of treatment, a rest of six months is given, 
at the end of which time a Wassermann test is again made. If 
positive, the course is repeated as in the first instance. If negative, 
the treatment is discontinued for another three months, when a 
Wassermann test is again taken. 

Even though the Wassermann remain negative, it is well for these 
patients, spring and fall, to take a brief course of mercurial treatment, 
and this for life. 

A positive Wassermann test at any time is an indication for a 
repetition of the course of treatment; equally severe and prolonged 
or less so, in accordance with the results of the treatment given 
before. 



938 DISEASES 

If syphilis be seen in its secondary stage, the dosage, intervals of 
treatment, and medication are the same as those advocated in 'the 
primary stage, excepting that sixteen arsenic injections instead of 
eight are given. Mercury is continued along through the entire 
series of arsenical injections short of producing any constitutional 
symptoms of the drug. Thereafter, at intervals of three months, a 
Wassermann test is taken and the course repeated but is less pro- 
longed. Thereafter, blood and spinal fluid Wassermann tests are 
taken at intervals of six months to a year. A positive Wassermann 
test at any time calls for a course of arsenic and mercury, gauged as 
to length and severity in accordance with the patient's capacity to 
maintain his health or make it better thereby. 

In the tertiary stage of syphilis, arsenic and mercury are given as 
in the secondary stage. Exceptionally, and particularly when these 
drugs have little effect, potassium iodide may be administered in 
increasing doses, always stopping short of toxic symptoms. This is 
particularly true in regard to vascular lesions. If the iodides are 
beneficial at all, they manifest their effects promptly; their long 
continuance is always devitalizing. Their over-use is characterized 
by coryza, gastro-intestinal disturbances, eruptions of the skin, 
ringing of the ears, mental depression, and loss of weight and appetite. 

For latent syphilis, mercury and arsenic are indicated, both being 
used with extreme caution ; basing the continuance of treatment on the 
resulting better health of the patient. 

Hereditary syphilis is controlled most successfully by treatment 
both parents before conception and treatment of the mother dur- 
ing pregnancy. Syphilitic patients with positive Wassermann tests 
should not marry. The Wassermann should be negative for two 
years. If the Wassermann test be positive when marriage takes place, 
the expectant mother should be treated in accordance with the 
principles laid down for the treatment of primary and secondary 
syphilis, to wit, full courses of from eight to sixteen doses of arsphena- 
mine, with mercurial inunctions. A syphilitic mother thus treated 
may give birth, indeed may be expected so to do, to a healthy child. 

As to the syphilitic child, intravenous injection of neoarsphen- 
amine 0.002 gram per pound body weight, may be given every two 
weeks until from four to six doses are administered. After an 
interval of six months the course of arsenic may be repeated. The 
arsenic should be supplemented by mercury inunctions. 

An inunction is thus given : 

The abdomen is washed with Castile soap and water, then with 
boric-acid solution. After thoroughly drying, \ dram of mercury 
ointment is rubbed into the skin. 

An abdominal binder is then applied and worn for twenty-four 
hours, at which time the skin is washed and the ointment again rubbed 
in. The same binder is worn for four days. Four days rest are given 
after four such treatments and the course is repeated four times. 



TONSILLITIS 939 

If the Wassermann test continues positive, further treatments are 
given at intervals of six months for two years. Spring and fall 
treatments throughout life is advocated for these syphilitic children. 

(For details as to the use of arsphenamine, neoarsphenamine and 
the various preparations of mercury and the iodides see articles on 
these drugs in Part II.) 

TETANUS. 

Immediately after the receipt of a suspicious wound, and before 
tetanic symptoms develop, the point of infection should be widely 
incised, washed clean, swabbed with a 3 per cent, solution of iodine, 
and then with peroxide of hydrogen. After this the wound should 
be loosely packed with gauze wet with iodine solution. 

The treatment of tetanus after the symptoms have developed is 
quite independent of its causation, so far at least as drugs are con- 
cerned, and, aside from the use of antitetanic serum, is virtually 
identical with that of strychnine poisoning, to which the reader is 
referred. (See Nux Vomica.) The value of the antitoxin for 
tetanus depends very largely upon how early it is given. When the 
disease has once developed, it cannot be of much use, but it should 
always be tried. It may be given in three ways: intravenously, into 
the cerebrospinal fluid around the spinal cord by intraspinal injec- 
tion (see Procaine) , and intraneurally, as it has been found that the 
infection travels along the nerve trunk. The intraneural method 
and the intraspinal injection method are the measures which should 
be resorted to whenever it is certain that infection by the tetanus 
bacillus has taken place, and they are particularly needful if the 
symptoms have already developed. In these cases the point of 
injection into the nerve should be well above the wounded area to 
head off the poison, as it travels up the nerve trunk. A prophylactic 
subcutaneous and intraneural injection of tetanus antitoxin should 
always be given when the injury has been produced by the explosion 
of the toy pistol, as this provides an almost sure preventive of the 
disease. (See Antitoxin, Part III, and Chloretone and Magnesium 
Sulphate, Part II.) The diet should be most nourishing. Con- 
tinuous immersion in hot water may be tried. 

TONSILLITIS. 



Inflammation of the tonsils occurs in three forms: superficial ton- 
sillitis, in which the mucous membrane covering the tonsils becomes 
inflamed through extension of a pharyngitis; follicular tonsillitis, in 
which the follicles are chiefly involved and pour out an excessive 
secretion, and, finally, true tonsillitis, in which the gland itself 
suffers from severe, widespread inflammation, phlegmonous in type. 
In all these forms the treatment to be instituted at the beginning 
is practically identical. The bowels should be opened by a saline 



940 DISEASES 

purgative, which in some cases should be preceded by small doses 
of calomel, the diet should be liquid and nutritious, and a fever 
and diuretic mixture should be given freely as follows: 

1$ — Tincturae aconiti Tllxl vel lxxx (2.6-5.3) 

Spiritus aetheris nitrosi f§j (30.0) 

Liquoris potassii citratis . . q. s. ad f S ii j (90.0). — M. 
S. — Dessertspoonful every three hours to a child of ten years; or a tablespoonful 
(15.0) to an adult. 

The best local treatment is to cleanse the tonsil with hydrogen 
peroxide and then paint it with pure guaiacol on a cotton applicator, 
or to apply powdered aspirin in the same manner. The second of 
these applications is very painful for a moment. 

Small doses of biniodide of mercury are sometimes useful to 
abort an attack of acute tonsillitis, ^io" grain (0.0003) every hour 
in water for four or five hours being the amount usually employed. 

Externally, an ice-bag should be applied about the throat, and 
as soon as the purgative has acted and the fever is reduced by the 
mixture just given, full doses of the tincture of ferric chloride 
be administered (20 minims [1.3] every three or four hours), in 
plenty of water, which preferably should be Vichy. 

In some instances hot fomentations about the neck and hot gargles 
seem to be more beneficial than the use of ice. Often a mild anti- 
septic gargle of phenol (1:100) in water will relieve the pain and 
the fetor. 

Chronic tonsillar enlargement does not require operation as often 
as is thought. Tonsillectomy is of graver import than appears at 
first sight. It should be done only by an experienced operator. 
Because tonsils are chronically enlarged and protruding that does 
not indicate operation, even if they are ragged. I agree with French, 
of Brooklyn, who says, "While all extensively diseased tonsils 
should be enucleated, it is probably safe to say that 80 per cent, 
of enlarged tonsils do not contain foci of infection, and therefore 
do not need to be completely removed, and, indeed, unless obstruc- 
tive to voice or respiration, do not need to be removed at all." They 
should be removed if they are the seat of septic foci, even if they 
are actually out of sight, or if subject to repeated abscess or if they 
are the cause of cervical adenitis. Their removal not only relieves 
local disease but diminishes the danger of rheumatic infection and of 
endocarditis. Local applications are rarely of much benefit. 

As a rule children under six years of age should not have the 
tonsils removed but washed out, but if the tonsils are distinctly 
septic they should come out at any age. In some cases infected 
crypts can be opened up and drained. 

TUBERCULOSIS. 

Tuberculosis affecting any part of the body is a manifestation of 
the fact that vital resistance has been decreased, for if not infection 



TUBERCULOSIS 941 

could not have taken place. The whole point at issue in cases of 
tubercular infection, as in all infections, is the building up of vital 
resistance to such a level that the battle between the invading 
bacillus and the cells of the body can be waged with victory for 
the cells, and as soon as they are able to cope with the infecting 
agent there is at once formed a protecting wall of inflammatory 
lymph which surrounds the area infected and protects the rest of 
the body from the bacilli that it contains. The means by which 
the greatest degree of vital resistance are obtainable is an outdoor 
life with exposure to as many hours of sunshine as possible and an 
abundance of fresh air. No drugs can equal the value of these 
outdoor agencies. (See Climate, Part III.) 

The second point to be borne in mind is that no drugs in tuber- 
culosis equal good food if it is well digested and taken in full amount, 
and he who disorders the digestion by drugs is doing his patient 
more harm than good. A good cook is a better friend to a tuberculous 
patient than a good druggist. (See Diet, Part III.) 

Cases of pulmonary consumption follow, rudely speaking, four 
well-defined lines. A very early stage sometimes comes to the 
care of the physician, and it is that in which the following history 
is given or a similar story is elicited. A patient, previously strong 
and well or of poor health, as the case may be, begins to lose vivacity. 
Life becomes a burden and exercise is distasteful. A slight daily 
chill and fever develop in morning or evening, and the physician 
who is careless treats the case as one of mild malarial poisoning. 
Careful examination, however, will show an area in the lung, gen- 
erally near the apex on one or both sides, where slight prolongation 
of expiration with a harsh inspiratory sound is heard, and where 
percussion will give impaired resonance or dulness. In other words, 
the first stage of phthisis is present, and the physician must resort 
at once to those active measures for the patient's relief which will 
be considered shortly. 

In another form a chill, a sweat, a loss of flesh and vigor, with, 
more prominent than all, a hard cough, sudden in its onset and 
rapidly becoming excessive with profuse expectoration, are the 
dominant symptoms. The wasting is extreme, the sweats are 
constant, and death may come in a few weeks. This is the form 
known as "galloping consumption." 

The third variety is ushered in by a gradual loss of vigor or a 
sensation of being a little unwell, or this form is brought before 
the patient's mind by a sudden acute hemorrhage, or several hemor- 
rhages rapidly succeeding one another. This variety passes along 
its course with varying rapidity. Death very rarely is due directly 
to the hemorrhage, although a secondary pneumonia may bring the 
end. In most cases the disease keeps on for months and the case 
dies from exhaustion. 

Last of all, the fourth class is made up of persons who gradually 



942 DISEASES 

pass from bad to worse: First, they "catch a cold," which hangs 
on longer than it ought, and, as soon as they are well, this is followed 
by another one, which is found more difficult to cure, until finally 
there is always a cough. Soon wasting comes on, strength is lost, 
and a long period of months ensues during which the progress of 
the case is now slow, now fast, the condition now better, now worse, 
until death ensues from wasting, pneumonia, or some other compli- 
cation. 

These forms and stages have been roughly outlined so that a dis- 
cussion of their treatment may be taken up with a clear idea of 
what is to be done. 

When a patient exhibits those physical signs which have been 
given as evidences of the early beginnings of phthisis, the physician 
should institute certain hygienic and medicinal measures. If the 
individual be earning a livelihood by following some confining occu- 
pation, this occupation must be given up and one undertaken which 
is carried on in the open air and yet not accompanied by too great 
exposure. Even if exposure is incurred, it is often better than the 
occupation previously followed: thus, if the patient be a bookkeeper, 
a printer, or a bookbinder, or a clerk kept much at a desk in an ill- 
ventilated room, a few wettings in the rain will do little or no harm 
if the patient is properly protected by the wearing of flannel shirts, 
which, when wet, are changed as soon as labor ceases, as under 
these circumstances the danger of catching cold is at a minimum. 
(See Climate, Part III.) The sleeping-room should be used with 
all the windows open or if possible a tent life is to be followed. 

The medicinal measures to be carried out in all cases of phthisis, 
except that known as the galloping form, are not numerous if we 
confine ourselves to the modes possessing any real value. For many 
years cod-liver oil has been sadly abused in the management of these 
cases, and has been given at all stages, owing to ignorance of its 
proper use. The writer believes that the following rules are never 
to be departed from: 

1. Never use cod-liver oil if it disturbs digestion. 

2. Never use it if fever is active. 

3. The use of cod-liver oil when rapid degenerative changes are 
occurring in the lung may be distinctly harmful, as it is not of any 
service, disorders the digestion, and destroys the appetite. 

4. Its best employment is in the earliest stages of the disease and in 
chronic fibroid phthisis. 

5. If the patient can take and assimilate cod-liver oil in addition 
to plenty of good food give the oil, if not, stop it. 

When the oil is used, it should be given as directed in the article 
on Cod-liver Oil. 

A remedy of some value as a palliative is creosote. Many cures 
have been -claimed from its use in the early stages of phthisis, and 
it has been highly lauded by a number of European clinicians. In 



TUBERCULOSIS 943 

the author's experience it is of value only when the presence of 
bronchitis requires the use of an expectorant. If it disorders diges- 
tion it is harmful. The opinion declared by Strumpell expresses so 
well the thought which the author was about to write when he 
read Strumpell's article that his words are here given: "Taking it 
all in all, we find that creosote, even in large doses, has no injurious 
effect on tuberculosis. At times we notice an apparently favorable 
symptomatic effect. We failed, however, to observe any real influ- 
ence exerted by creosote on the progress of the disease." (See 
Creosote.) When creosote is used internally it may be given in 
the following formula: 

ty — -Creosoti (beechwood) . . ' . . . . gtt. xxxij vel f 3j (2.0-4.0) 

Tincturse gentianse f §j (30.0) 

Alcoholis fSJ (30.0) 

Vinialbi q. s. ad fgiv (120.0).— M. 

S. — Teaspoonful (4.0), in water or wine, three times a day. 

Better still, creosote may be given in ascending doses (1 minim extra 
each dose) in, milk or wine. 

Often a 1-minim (0.06) dose three times a day may be increased 
to 5 minims (0.3) in the same period with advantage. Sometimes 1 
or 2 minims (0.06-0.12) in capsule are as useful as the formula just 
named. (For methods of administration see Creosote; also, see 
Guaiacol and Creosote Carbonate.) 

Creosote may also be inhaled in the spray from a steam atomizer 
or by means of an inspirator fitted over the nose and mouth and 
made of perforated zinc with a sponge at the edge to hold the drug. 
A very good method is to wet the sponge with creosote, alcohol, 
and water, equal parts, or to use the creosote alone if coughing is 
not too severe. Another useful mixture consists of equal parts of 
terebene, iodide of ethyl, and chloroform. This last mixture is 
most useful when the secretion is tough and tenacious, and should not 
be used in the presence of acute irritation due to inflammation. 
Such inhalers are very cheap, not easily broken, and readily worn. 
(See Inhalations.) 

If the cough is excessive, a little spirit of chloroform placed on 
the sponge of the inhaler will often relieve it, or a mixture of mor- 
phine and wild-cherry bark may be given as follows: 

I^ — Morphinse sulphatis gr. j vel ij (0.06-0.12) 

Syrupi pruni virginianse f g ii j (90.0). — M. 

S. — Teaspoonful (4.0) every three hours. 

Or the following: 

1} — Spiritus chloroformi fgss (16.0) 

Morphinse sulphatis . gr. j vel ij (0.06-0.12) 

Syrupi pruni virginianse f5ii.i (90.0).— M. 

S. — Teaspoonful (4.0) every four hours. 

In still other cases 2 to 10 minims (0.1-0.6) of a good fluid extract 
of cannabis, or J to J grain (0.008-0.015) of the solid extract, 



944 DISEASES 

will act with surprising benefit and stop the cough. Heroin in 
small doses is also useful when there is an idiosyncrasy to morphine. 

Very often during the course of phthisis localized spots of pleuritic 
inflammation develop which give rise to pain. The best treatment 
is to apply a small blister or to paint the spot with iodine. 

(For the treatment of Hemoptysis see Hemorrhage.) 

Laryngeal phthisis, one of the most serious complications of this 
disease, is best prevented by ordering the patient to inhale the steam 
arising from boiling water which contains corrosive sublimate in the 
proportion of 1 : 10,000. If a proper watch is kept for evidences of 
a general mercurial effect, and this measure stopped at once when 
tenderness of the gums appears, no danger exists. Before the inhala- 
tion takes place a spray of cocaine (4 per cent, solution) should be 
thoroughly used. 

The treatment of laryngeal phthisis itself is various. The best 
method is that in which lactic acid is used. By the aid of a laryn- 
geal mirror and a cotton applicator a 10 per cent, solution of lactic 
acid is applied to the spots which are involved. As this is generally 
quite painful, cocaine solution should first be used. Gradually 
the strength of the lactic-acid solution should be increased to 60 
per cent, if the weaker solutions do not check the disease. Very 
valuable results have been obtained by this method. 

The second method in point of value is that of iodoform insuffla- 
tions. A powder of iodoform alone is too light for satisfactory 
propulsion into the larynx, and powdered talc should be added to 
it in small amount, with ^ grain (0.004) of morphine to each dram 
(4.0) of iodoform. The odor is generally disagreeable to the patient, 
but if a cocaine spray be first applied to the fauces and the operator 
is skilful, very little coughing is produced. As iodoform is a local 
anesthetic, it relieves the pain in the larynx, acts as an antiseptic 
and alterative, and is peculiarly obnoxious to Bacillus tuberculosis. 

Camphoric acid in 20- to 30-grain (1.3-2.0) doses is the best internal 
remedy for treating night-sweats. (See Camphoric Acid.) 

When the night-sweats are very profuse, hypodermic injections 
of atropine in the dose of T i^ to ^ grain (0.0004-0.0006) are useful 
in some cases, and the efficiency of this treatment may be increased 
by the use of an alum sponge-bath at bedtime. A solution of alum, 
10 to 20 grains to the ounce (0.6-1.3:30.0), may be sponged over the 
body, or sulphuric acid may be added to water in the proportion of 
1 dram to the pint (4.0-480 cc), and used in the same way as the 
alum solution. Formaldehyde solutions may also be used. 

Sulphuric acid is often given internally with advantage in these 
cases of sweating. 

Reference should be made to the treatment of pulmonary tuber- 
culosis by artificial pneumothorax. This method is based on the 
view that the collapse and consequent rest of the lung will aid in 
arresting the process. It is applicable only in those cases in which the 



TUBERCULOSIS 



945 



lesions are almost solely on one side, since it is necessary that the lung 
not compressed shall compensate for the work of the collapsed lung, 
and that there shall not be pleural adhesions which cause the lung 
to adhere to the chest- wall. For these reasons both sides of the 
chest should be carefully studied by the aid of the :r-rays before 
instituting the procedure, and if the x-rays reveal the position of 




Fig. 142. — Robinson's apparatus for artificial pneumothorax. Two bottles of 
2000 cc. capacity are employed. One is stationary and filled with water containing 
2 drams of pyrogallic acid to take up any oxygen which may enter in conjunction with 
nitrogen. Nitrogen gas is then forced into stationary bottle (A), displacing the water 
back to bottle B. At completion of this displacement the apparatus is ready for 
use. On opening certain cocks the water in bottle B replaces the nitrogen in bottle 
A, gradually filling it. The difference in the water levels of the two bottles represents 
the pressure under which the nitrogen is injected, the rapidity of its injection being 
regulated by the size of the opening in any one of the cocks. When bottle B is full 
the maximum pressure is obtained, amounting to about 14 cc of water. As the water 
levels approach one another bottle B may be raised, thus maintaining the pressure until 
most of the nitrogen has been displaced, when the pressure is necessarily reduced. 
With this hydrostatic mechanism the pressure may be varied at will, never attaining 
the dangerous limit. The arrangement of cocks, D, E and F corresponds to the sub- 
stitution of a three-way cock at point G. In other words, with cock D closed and E 
and F open, a direct connection is established between the thoracic cavity and the 
manometer. With cock F closed and C, D and E open, connection is made between the 
confined nitrogen and the manometer, thus recording the pressure represented by the 
difference in water levels of bottles A and B. With cock E closed and all others open 
the nitrogen passes directly from bottle A into the pleural cavity. 



one or more cavities to be such as to prevent drainage into a bron- 
chus, the operation is contraindicated because septic absorption will 
ensue. The fact that the disease on one side is very far advanced 
does not contraindicate this plan. Indeed, some of the best results 
have been obtained in cases so far gone that any method was accept- 
able to the patient. 
60 



946 DISEASES 

If the pneumothorax is properly induced the method is not very 
dangerous, but cases of pleural shock and pleural effusion as sequences 
have been reported. Neurotic and lymphatic patients and those 
advanced in years or very young are less favorable subjects than 
others. 

The results which accrue usually consist in prompt diminution of 
cough and expectoration and a decrease in the systemic manifesta- 
tions of the disease. So, too, it has been found a most efficient 
means of arresting profuse pulmonary hemorrhage. If the other 
lung is in fairly good condition there is little dyspnea. This treat- 
ment is contraindicated if adhesions so fix the diseased lung that it 
cannot be made to collapse. 

Several methods of introducing the gas are resorted to. The 
simplest is that by Forlanini. This consists in introducing a small 
aspirating needle, preferably in the fifth or sixth intercostal space, 
in the mid-axillary line or anywhere the pleura is free, the patient 




Fig. 143. — Floyd's modification of Brauer's needle for use in pneumothorax therapy. 

lying on the unaffected side. Through this needle is slowly passed 
pure nitrogen gas to the extent of from 200 to 300 cc, but it is not so 
much a question of the amount of gas as of the pressure exercised. 
The lung should not be compressed by a very large single injection 
except when it is necessary to control hemoptysis. (See below.) 
About this quantity is injected on alternate days until complete 
collapse of the lung is gradually induced. The degree of collapse 
should be estimated not only by ordinary methods of physical 
diagnosis but by the aid of the x-rays. Nitrogen gas is used because 
it is less rapidly absorbed than atmospheric air, and so better main- 
tains the pressure but atmospheric air is commonly employed. The 
gas or air should be warmed to body temperature before it is injected. 
A U-shaped glass tube partly filled with water, and provided with 
a scale in millimeters of displacement, should be connected with 
the tube, which carries the gas from the container to the chest. 
The branch running to this U-shaped tube should be provided with 
a two-way cock, as by this means the negative pressure in the chest 



TUBERCULOSIS 947 

cavity after the needle is introduced can be measured and the posi- 
tive pressure of the gas delivered to the chest can readily be estimated. 
The negative ' pressure fluctuations caused by respiration should 
equal about 10 mm. or more of displacement in the manometer. 
If such fluctuations do not occur the injection is contraindicated, 
since their absence indicates that the lung is bound to the chest- 
wall by adhesions and cannot be made to collapse. The positive 
pressure of the gas should be from 40 to 250 mm. of water but less 
than 250 is better. After the needle is introduced it should be 
moved up and down to determine that its point is not engaged in 
the lung tissues. 




Fig. 144. — Showing the degree to which the left lung may be compressed by artificial 
pneumothorax within nineteen days. (Amrein and Lichtenhelm.) 

Even when nitrogen gas is used so much as 80 to 100 cc may be 
absorbed in each twenty-four hours and, therefore, repeated injec- 
tions must be made to maintain the collapse. This is the whole 
point in the treatment. To repeatedly compress the lung and 
then let it expand is harmful. The fluoroscope must be used to 
determine when the next dose is needed. 

As a rule the pressure must be continued several months before 
the lung heals in its collapsed form. Often when the treatment is 
stopped after some months, and when the patient is so greatly 
improved that it is thought wise to stop, the lung will expand slightly. 

Finally, it is manifest that the most rigid rules of asepsis must be 
constantly adhered to, as a pyopneumothorax may readily be induced 
through errors in the technique. 



948 DISEASES 

It need hardly be added that this plan is to be instituted in only 
a very limited class of cases, as, for example, those in which the 
cough is exhausting, hemoptysis is repeated or dangerous in amount, 
and the lung is suffering from fairly widespread and advanced lesions 
which are tending to break down and form cavities; in other words, 
in cases not at death's door but otherwise hopeless cases. 

TYPHOID FEVER. 

Any attempt to review the various forms of treatment of the 
disease known as typhoid fever is absolutely impossible, owing to 
the very numerous theories and practices put forward by various 
clinicians. What is said under the general heading of Fever and 
under the consideration of Cold, Part III, and also under Antipyrine 
and Acetanilid, gives sufficient information as to the treatment of 
febrile movements, and the care of the patient beyond this point 
in nearly all cases depends upon the severity of the attack. 

Before going farther, however, the writer desires to insist very 
strongly upon one fact— namely, that a case of typhoid fever is 
not curable in any degree. No remedy yet found, except it act 
through the prevention of complications, can shorten the course 
of the disease. We can only guide the patient safely to health when 
the storm of disease comes on, and we cannot stop the storm. 

Not only should the facts of the last paragraph be carefully borne 
in mind, but the physician must also remember that he is treating 
an exhausting disease— not a disease which runs a violent course 
for a few days and strands the patient sick and weak, but convales- 
cent, upon the shores of health, but one in which, after sapping the 
strength for weeks, some sudden intercurrent malady or accident 
may ensue which will speedily kill him if every grain of strength 
is not preserved for the struggle. The physician should always 
put every case in which there is a suspicion of typhoid fever to bed 
at once, and keep the patient there until the disease has passed or 
fails to develop. Every muscular movement unnecessarily made 
is a waste of force, and, in consequence, everything should be done 
for the patient, and not by him. A bed-pan should always be 
employed, the patient not being allowed to sit erect upon a commode. 

Remembering, too, that a typhoid fever patient is subjected to 
prolonged wasting fever and toxemia for many days, his nutrition 
should be maintained by the use of a nourishing diet easy of diges- 
tion. In addition to milk he should also receive one or two soft- 
boiled eggs each day, arrowroot and perhaps thin corn starch, pro- 
vided they agree with his digestive powers. If diarrhea is not 
present, broths may be given, but it must be recalled that Brieger 
has shown that typhoid bacilli do not readily reproduce themselves 
and their poisons in peptonized or well-digested milk, but do so very 
actively in meat-broths or jelly which has not been acted upon by 



TYPHOID FEVER 949 

the digestive juices. Milk diet is therefore evidently better than 
a broth diet in typhoid fever, and we once more are able to explain 
an empirical fact by a scientific discovery. There is no reason for 
using liquid instead of solid foods, except the difficulty of digesting 
the latter. (See next page.) 

Alcohol has been used in all stages of typhoid fever as a stimu- 
lant, as a giver of force to the system, and as an aid to digestion, but 
its real value is found when actual depression exists. A very large 
part of the profession believe that the mere presence of an abnor- 
mally high temperature contraindicates the use of alcohol. Mere 
high temperature does not do so, however. High temperature of 
a sthenic type, with a full, tense, bounding pulse and all the signs 
of a disease attacking one in the full vigor of life, may preclude its 
use; but in the high temperature of advanced typhoid, with the 
marked asthenia often present in that stage, alcohol should be given 
whenever the heart-sounds are feeble. Under these circumstances 
the tissues which the man can afford to lose are gone, and much of 
his vitality is greatly encroached upon: the alcohol yields force to 
the body, and is burnt up in great part, keeping the flagging heart 
pumping the blood through the lungs and systemic circulation, when 
otherwise the circulatory depression would result in hypostatic con- 
gestions, if not in more widespread circulatory disorder. Alcohol 
acts rather by restoring the equilibrium of the circulation and giving 
force to the body than by a direct stimulant effect. It may also 
increase the bacteriolytic power of the blood. In those cases in 
which a temporary loss of heart-power is due to hemorrhage or to 
some sudden severe depression, alcohol is one of the remedies to be 
employed— in a hot and concentrated form. (See Alcohol.) 

A no less useful and valuable result obtained by the use of alcohol 
in the later stages of exhaustive fevers is the part that it plays in 
aiding digestion. The writer has elsewhere defined the difference 
between the influence of alcohol in the artificial digestion of the 
test-tube and that occurring in the stomach. Aside from experi- 
mental evidence, every-day experience has taught the gourmand 
that alcohol, in a fairly concentrated form, enables him to digest an 
amount of food which under ordinary circumstances would remain 
unchanged in his stomach. 

The physician ought not to use alcohol as a routine measure in 
every case without a rational idea of why he does so, nor without 
a clear idea as to what indication is met by its use. In many cases 
it is not needed at any time. 

That alcohol may be misused and cause great harm is, of course, 
known to every practitioner of medicine. So long as it reduces the 
temperature and lowers the rate of the pulse, causes a moist skin 
and tongue, and quiets nervous twitchings, it does good, and only 
up to this point is it to be employed. 

The treatment which is used by the author for many years in his 



950 DISEASES 

wards at the Jefferson Medical College Hospital has given him 
results which the application of other methods has failed to give, 
and is as follows: 

As soon as the patient enters the house he is washed or bathed 
and placed in bed, and required to remain there He is assured 
that the more quietly he lies the more mild and safe will be the 
course of his attack, and is made to use a bed-pan and urinal, and 
never allowed to get up. He receives several small doses of calomel, 
followed, if the bowels are not moved, by a mild saline purge, such 
as a Seidlitz powder. 

Whenever the temperature reaches 102° F. he is given cold spong- 
ing with friction or an ice rub. This is essential. (See Cold, Part 

in.) 

I am one of those who are firmly convinced that for many years 
we have been making a grave mistake in confining patients suffer- 
ing from typhoid fever to a purely milk diet. We must recollect 
that the average adult requires at least 2500 calories a day for normal 
existence, and as each quart of milk represents only about 500 to 
600 calories, it is evident that for a patient to receive the total 
number of calories required for the maintenance of his body he 
must drink not less than four and a half quarts of milk a day. These 
facts further impress us with the utter inadequacy of the pure milk 
diet in this disease. Nor can we help appreciating the fact that we 
are overloading the organs of absorption and elimination with an 
excess of fluid, which certainly cannot be advantageous, although of 
course an excess of liquid in typhoid fever is preferable to a lack of it. 

In some instances, milk agrees with the patient if it is partly 
diluted with plain soda-water, Vichy or Apollinaris water. 

Again, I can see nothing in the clinical history or pathology of 
this disease which in any way justifies us in disordering metabolism 
by the institution of a rigid milk diet. 

It is my custom to give all patients, after the first week of typhoid, 
from one to two soft-boiled eggs a day in addition to the ordinary 
allowance of milk, and to vary their diet by the use of curds and 
whey, rice which has been boiled to a pulp, barley, and wheat gruel, 
and a cup of corn starch with vanilla or some other flavoring sub- 
stance of a like character. As a result I very rarely see the marked 
ataxia which is so common a symptom in convalescence from the 
typhoid fever. The patient's nutrition is so well preserved that he 
is but little more emaciated than many cases of acute pneumonia at 
the time of recovery. Secondary complications like furuncles and 
bed-sores are almost unknown, for by the use of a plentiful supply of 
food the patient's vital resistance is maintained to such a degree 
that simultaneous collateral infections do not take place. The 
average case of convalescent typhoid fever is a fair mark for any 
infection because it 'is half-starved. 



TYPHOID FEVER 951 

When starches are used, it is the author's invariable rule to give 
taka-diastase, in the dose of 5 grains with each meal. 

Recognizing that typhoid fever is characterized by a deficient 
secretion of digestive juices, all these patients receive hydrochloric 
acid and pepsin when proteids are administered, and taka-diastase 
and pancreatin when carbohydrates are used. 

For the dry and sordes-covered tongue a mouth-wash of glycerin 
and water, half and half, to which may be added a little lemon-juice, 
is used, and it is important to keep the mouth constantly cleansed, 
as by this means swallowing is not interfered with through cracking 
of the lips, tongue, and buccal mucous membrane, pulmonary infec- 
tion is avoided, and facial erysipelas and parotitis are prevented. 

If constipation is very obstinate and continues over one day, an 
injection is employed, and if this, after being used twice, fails to act, 
a dose of calomel, \ grain (0.001) every fifteen minutes until a grain 
has been taken, is prescribed, and, if no movement occurs in twelve 
hours, is followed by half a bottle of citrate of magnesium, or a tea- 
spoonful of liquorice powder is given. In other cases small doses 
of cascara sagrada are equally useful. Violent purgatives should 
never be used, for obvious reasons. Rectal injections should be 
given some hours after the purgative is taken, to aid its action, since 
not infrequently the laxative causes the contents of the small intestine 
to flow into the large bowel, which is too inactive to extrude them. 

When diarrhea becomes troublesome— that is, more than three 
or four passages a day— the following will be of service: 

1$ — Acidi sulphurici aromatici f 3ij (8.0) 

Fluidextracti hsematoxyli f3iij (12.0) 

Syrupi zingiberis fgiij (90.0). — M. 

S. — Teaspoonful (4.0) in water every hour until relieved. 

Should the stools be excessively fetid and tympanites be marked, 
guaiacol carbonate or phenol sulphonate of sodium may be given as 
an intestinal antiseptic, or, as soon as any evidence of tympanites 
or much meteorism comes on, turpentine may be given, as follows: 

3— Olei terebinthinse f5ij (8.0) 

Syrupi acaciae q. s. ad fgiij (90.0). — M. 

Fiat emulsum. 

S. — Teaspoonful (4.0) in milk three times a day. 

At the same time it is well to employ a turpentine stupe over the 
abdomen. (See Turpentine.) Where the tympanites is excessive 
it may be relieved by an injection made as follows: 

3— Olei terebinthinse . ' f 3J to 3ij (4.0-8.0) 

Oleiolivae fgiv (120.0) 

Emulsi asafcetidae Oj (480 cc). — M. 

S. — Use as an injection. Shake well before using. 

When the tympanites is severe, half an ounce (16.0) of Hoffmann's 
anodyne may be used in place of the turpentine. 

In the later stages of typhoid fever, as convalescence is approached, 



952 Diseases 

turpentine is often useful, as it seems to cause rapid healing of the 
intestinal ulcers and checks diarrhea. 

Much has been said about the value of purgatives and so-called 
intestinal antiseptics in typhoid fever, and extravagant claims made 
for them. Suffice it to state that while they may be indicated in 
certain cases they are not to be used as a routine plan of treatment, 
because the skill of the true physician is to give each patient what 
he needs— not to give all the same treatment. Typhoid fever 
cannot be aborted; it can only be modified in the sense that we 
place our patients in the best possible physical state to withstand its 
ravages. 

A point of importance in the treatment of typhoid fever is to 
see that the patient receives enough water in twenty-four hours. 
Owing to his apathy he often does not complain of thirst and the 
kidneys are not flushed of impurities by fluid. Some perfectly pure 
water, such as Poland water, should be freely given to help eliminate 
toxic materials through the kidneys. Should toxemia be severe, the 
use of cold is essential, and if in addition emaciation be marked, it 
is wise to employ hypodermoclysis. (See Part III.) 

Not infrequently cases are met with in which toxemia with mental 
depression is well developed, yet in which the temperature is below 
102° F., and so the use of cold sponging seems contraindicated. 
Active friction with tepid water and alcohol is now of value. If 
the temperature is normal or subnormal, the patient may be sponged 
with hot water. The value of this measure does not lie so much in 
the temperature of the water as in the reaction and consequent read- 
justment of the circulation. 

As during the later days of the disease and in convalescence a 
large number of typhoid bacilli are in the urine, the routine use of 
urotropin or uritone, as a urinary antiseptic, is resorted to by many 
physicians. It may also be used to prevent cholecystitis arising 
from this infection and to prevent the spread of the disease by the 
dejections of so-called "typhoid carriers." (See Hexamethylena- 
mine.) 

The complications of typhoid fever of the most serious import are 
hemorrhage from the bowel, pneumonia and pleurisy, and perforation 
of the bowel. 

The hemorrhage from the bowel may be treated as indicated 
under that heading (see Hemorrhage), and the pneumonia or pleurisy 
should be treated as are these diseases when they occur alone; but 
it is to be remembered that the patient is an asthenic adynamic case, 
and must not be depressed and may need stimulation. 

When perforation of the intestine occurs, only enough morphine 
should be given to relieve agony. Warm applications should be 
used over the belly and down the limbs, and stimulants given if 
needed. In all cases where it is possible to find a surgeon capable 
of doing a skilful abdominal section, a consultation should be had 



XJBMMIA 953 

at once. As a rule, the operation should be performed immediately. 1 
(See Shock.) 

As stated at the beginning of this article, cold bathing is very 
important and should always be employed in one of its forms if the 
fever is high, except in the presence of pneumonia, hemorrhage, or 
perforation, provided the patient reacts. 

For a number of days after the patient begs for solid food it should 
not be allowed, for he will ask for it long before he should have it; 
but if the temperature remains normal after seven days, solid food 
may be used and the patient gradually brought back to an ordinary 
simple diet. 

UREMIA. 

The treatment of this dangerous manifestation of renal disease is 
often futile, but always to be resorted to with the recollection that 
wonderful recoveries sometimes occur under judicious management. 
It matters little whether the onset of the symptoms has been gradual 
or instantaneous: in either event the prime endeavor must be to 
rid the system of the poison which is threatening life. This can 
only be accomplished by aiding its elimination through the bowels, 
skin, and kidneys. The second indication is to support the vital 
organs until the emunctories have had time to act Often this 
second indication will be more pressing than the first, and the physi- 
cian will have to give stimulants at once The third indication is 
to arrest any convulsive seizures. 

The methods to be resorted to for the elimination of the uremic 
poison are external and internal, externally the hot pack being 
resorted to to increase the activity of the skin. (See Heat, Part 
III.) Internally we give elaterium or elaterin in the dose of \ 
grain (0.01) or ys grain (0.004), respectively, for the induction of 
watery purging, which at once aids elimination through the bowel 
and relieves dropsy if present. The elaterin should be dissolved in 
a few drops of alcohol or in whisky. The medication directed to 
increased action of the skin may consist of small doses, hypodermi- 
cally— say J grain (0.008)— of hydrochloride of pilocarpine with 
strychnine ^o grain (0.003), but the pilocarpine is contraindicated 
unless the heart is strong and acting properly and if there is present 
the slightest tendency to pulmonary edema. Even if the heart 
seems strong its use is not devoid of danger. It may be used in 
conjunction with the hot-pack or hot-air bath. As a rule it is better 
to bleed, if there is venous congestion, and follow this, if need be, by 
hypodermoclysis. 

In every case of uremia the blood-pressure should be taken and 
an estimate made of the strength of the heart muscle by a study 
of its first sound and the vigor of the pulse. If the blood-pressure 

1 For discussion of this condition see the author's work on the Medical Complications 
and Sequelae of Typhoid Fever. Lea & Febiger, Philadelphia, second edition, 1909. 



954 blSEASES 

is much above normal, say 150 or 160 millimeters of mercury, stimu- 
lants are not needed, as a rule, but nitroglycerin ^ grain (0.001) or 
sodium nitrite 1 to 2 grains (0.06-0.12) may be given. Aromatic 
spirits of ammonia and Hoffmann's Anodyne are valuable if the heart 
is weak, and are to be followed by strychnine and digitalis if necessary. 

For the support of the heart and respiratory function we employ 
strychnine hypodermically or by the mouth in the dose of ^ to to 
grain (0.003-0.006), and follow it by the more powerful stimulant 
digitalis in the dose of 30 minims (2.0) of the tincture by the mouth. 
Hypodermic injections of ether are also very valuable if the tissues 
are not too edematous for absorption to occur. 

Should pulmonary edema threaten, atropine may be given in full 
dose with advantage and dry cups should be placed over the bases of 
both lungs. 

The convulsions, if present or threatened, are to be combated by 
the use, after the bowels have been washed out, of an enema of 20 
grains of chloral (1.3) and 60 grains (4 0) of bromide of sodium in 3 
ounces (90.0) of starch-water, and the hot pack will also be of value, 
not only to produce sweating, but for its sedative influence on the 
nervous system. Should the convulsive tendencies be marked, amyl 
nitrite inhalations may be employed until the chloral and bromide 
can be absorbed. 

Two other remedial measures should be resorted to in case of 
uremia for the relief of all symptoms— namely, full venesection if 
the pulse is bounding, and hypodermoclysis. (See Part III.) Vene- 
section is contraindicated in the feeble, but as much as 1 to 2 pints 
(480-960) of blood may be withdrawn in a sthenic case from a vein 
in the arm. After the bloodletting or during its progress hypoder- 
moclysis may be performed or a saline solution transferred into a 
vein. (See Transfusion.) Often deep insensibility is speedily 
removed by venesection which should be regarded as the sheet- 
anchor of treatment in those cases which have venous turgescence. 
The author also regards hypodermoclysis and intravenous transfusion 
of salt-solution as most useful methods of treatment in this state, 
unless pulmonary edema is threatened or dropsy exists. 

VITREOUS DISEASES. 

Vitreous opacities may be either dust-like, flaky, or dense and 
membranous. They impair vision in proportion to their number and 
density, and are to be detected with the ophthalmoscope. Patients 
observe them as floating dark spots in their field of vision, because 
the opacities cast a shadow upon the retina. If vitreous disease is 
syphilitic, the usual remedies are indicated. Hypodermic injections 
of pilocarpine or sweating by the electric cabinet act favorably. 
Galvanism has been recommended. Often opacities are due to 
uveitis, choroiditis, and chorio-retinitis, and these states must be 
treated according to their causation. 



VOMITING 955 



VOMITING. 



Vomiting is a symptom, not a disease, and arises from a large 
number of causes, some of which are very unimportant, others very 
serious. The most common cause is probably imperfect digestion, 
with all that this implies; that is, gastro-intestinal irritation and 
perversion of normal function. Additional causes are cerebral 
hemorrhage, tubercular meningitis, cerebritis, uremia, or diseases 
of the middle lobe of the cerebellum, all of which conditions cause 
irritation of the vomiting center. 1 In children it is occasionally due 
to a disorder of metabolism which results in a state characterized by 
acidosis as in so-called cyclic vomiting and in cholera infantum. 

Some of these states may be considered as lesions of a centric 
character which directly or indirectly cause the vomiting center to 
send out impulses. On the other hand, it is worthy of note that 
under certain circumstances vomiting may be reflex and dependent 
upon irritation of the nerves of the stomach or elsewhere which 
convey impulses to the center and the muscles whose activity results 
in vomiting. These conditions are well represented by the vomit- 
ing which comes on in incarcerated hernia, or in pregnancy, or in 
that occurring during the passage of renal or hepatic calculi, or 
in indigestion. 

It is important to bear in mind that peripheral vomiting due to 
disorder of the gastric walls may be dependent upon two conditions. 
The mucous membrane and its nerves may be overexcitable or they 
may be depressed. For this reason we shall find that two modes of 
treatment are necessary when this subject is considered below. 

The mechanism of vomiting consists in the closure of the pyloric 
sphincter, the contraction of the gastric muscles from the pylorus to 
the cardia, and at the same time, and more important than these 
movements, the contraction of the supplementary respiratory and 
abdominal muscles, which so compress the stomach as to drive its 
contents through the open esophagus. The violence of the muscular 
contractions in the abdominal walls is greatest when the stomach is 
partly empty, and gives rise to the pain and exhaustion accompany- 
ing the condition known as retching. The practical point to be 
learned from this is that vomiting is always easier when the stomach 
is not empty; so if an emetic is to be given on an empty stomach, as 
the popular expression runs, a large amount of liquid should preceed 
or accompany it if possible. Dogs vomit easily because of the 
development of their gastric muscles, but they render the effort 
easier by filling the stomach with air or grass, and so completely 
fill the viscus that its walls can contract on a resisting mass. 

Having described the mode and causes of vomiting, it remains to 
consider its treatment. 

It is needless to remark that the vomiting of cerebral disease 

1 See Symptoms in the Diagnosis of Disease, by the author. Lea & Febiger, 
Philadelphia. 



956 DISEASES 

is very intractable, and that very active agents must be used to 
check it The vomiting following etherization is often centric, and 
should be treated, as should all forms of obstinate emesis by the 
injection into the rectum of 40 grains (2.4) of sodium or potassium 
bromide and 20 minims (1.2) of tincture deodorized opium in 4 to 8 
ounces (120.0-240.0) of starch- water. If this does not check the 
vomiting, a second injection may be given two hours after the first. 
A very valuable remedy in this state is acetanilid given in 1-grain 
(0.06) doses every half-hour in a dram of brandy with cracked ice 
(see Acetanilid), and it is well to remember that inhalation of the 
fumes of vinegar from a cloth wetted with it will often be of service. 
In other cases relief is obtained by washing out the stomach. 

When vomiting seems to be due to hyperexcitability of the gas- 
tric mucous membrane, so that very small amounts of food when 
swallowed are at once rejected, local anesthetics and depressants 
are needed, the chief of these being chloretone, cocaine, and' aconite. 
The last two drugs, however, have disadvantages, because in effec- 
tive dose their general physiological action may be very severe and 
almost poison the patient. When given as antiemetics, these drugs 
act as local anesthetics, or, in other words, by paralyzing the periph- 
eral sensory nerves of the stomach. Cocaine should be given in 
the dose of 2 to 3 minims (0.1-0.2) of a 4 per cent, watery solution 
every fifteen minutes until 10 minims (0.6) are taken. And it is 
best given in capsule so as to exert all its effects on the stomach 
rather than on the mouth and esophagus. The aconite should be 
used in the form of the tincture, the patient being placed flat on 
the back, so as to withstand the ensuing cardiac depression with the 
least inconvenience, and 6 to 10 minims (0.4-0.6) of the tincture 
given in a little water every thirty minutes until the rapidly weak- 
ening pulse forbids its further use. This drug may be resorted to 
in all forms of vomiting due to irritability of the stomach, but it is 
contraindicated in cases of debility or weakness. 

Two grains of chloretone given in capsule or dissolved in a little 
brandy and poured over cracked ice and given in very small doses 
are useful. This treatment may be repeated every hour for 5 doses, 
and is very efficient. 

Sometimes a prescription of the following character is of service, 
the bismuth acting as a coating to the walls of the stomach, pro- 
tecting and soothing them: 

]$ — Bismuthi subnitratis 3iij (12.0) 

Fluidextracti aconiti miij vel vj (0.2-0.4).— M. 

Fiant chartulas, No. x. 

S.— One powder every half-hour. 

In other cases of the same type the following is useful, and is to 
be preferred if, owing to active fermentation, the vomiting is exces- 
sive (the creosote or phenol being a local anesthetic and antiseptic) : 

1$ — Phenolis vel creosoti (beechwood) . . . gtt. x vel xx (0.6-1.3) 

Bismuthi subnitratis 3iij (12.0).— M. 

Fiant chartulas, No. x. 

S.- — One powder every hour. 



VOMITING 957 

In other cases 1 drop of tincture of iodine and 1 drop of phenol in 
a couple of drams of water will act very well. 

Sometimes pure chloroform in 1- or 2-drop (0.06-0.1) doses, in a 
little water, does good; and dilute hydrocyanic acid, in the dose of 
2 to 5 minims (0.1-0.3) is also of value in like instances, given in 
a tablespoonful (15.0) of water. 

In other instances small repeated doses of nitroglycerin do good. 
Particularly is nitroglycerin useful in the nausea which often follows 
the use of opium, although this symptom is best prevented by its 
preliminary use. The dose used should be about -^ grain (0.0002) 
every half-hour. 

The treatment of a case of vomiting dependent rather upon 
depression and debility of the stomach than upon irritation is directed 
to the administration of gastric and, it may be, systemic stimulants. 
The chief of the gastric stimulants is ipecac in small doses, and it is 
this employment of a drug generally resorted to for the production 
of emesis by physicians which has caused homoeopaths to claim 
that the regular school obey the rule of similia similibus curantur 
and infinitesimal dose. The claim only holds good on its face, for 
we do not use an infinitesimal dose, and obey no law, but use com- 
mon sense. Ipecac is an irritant, even to the skin, and it is partly 
by its irritant effects in large doses that it causes vomiting by excit- 
ing the stomach to a point over and above its normal condition. 
In the vomiting depending upon gastric debility and depression small 
doses of ipecac do good because they irritate the stomach sufficiently 
to restore its normal tone without going to the other extreme of 
hyperexcitation. Under these circumstances a drop dose of the 
wine of ipecac, or \ grain (0.015) of the powdered ipecac, every 
hour, is of the greatest value, often succeeding after all other remedies 
have failed. 

In other instances tincture of nux vomica, given in J- to 1-minim 
(0.03-0.06) doses, is useful as follows: 

fy — Tincturse nucis vomicae gtt. iv vel viij (0.25-0.5) 

Aquae cinnamomi f 5j (30.0). — M. 

S. — Teaspoonful (4.0) every half-hour or later. 

In the nausea and vomiting following an alcoholic debauch J to 1 
minim (0.03-0.06) of Fowler's solution every two hours, or before 
food, often gives relief, and it may be used in some cases in place of 
the nux vomica and ipecac. Another useful measure for the cure 
of alcoholic nausea if the tongue is heavily coated is the use of full 
doses of hydrochloric acid, 5, 10, or 15 minims (0.3-0.6-1.0) of the 
dilute acid in half a tumblerful of water, repeated every two hours. 

In all cases of persistent vomiting counterirritation should be 
applied over the stomach in the form of a mustard plaster, or, if 
preferred, an ice-bag may be applied to the nape of the neck, the 
lumbar spine, or the epigastrium. Sometimes the application of the 
positive electrode of the rapidly interrupted induced or faradic 



958 DISEASES 

current between the sterno-clavicular muscles while the negative 
electrode is placed on the epigastrium will give relief. In still other 
cases the skin over the vagus nerves in the neck may be frozen by 
the use of a chloride of ethyl spray, or blisters may be applied in 
its stead. 

The food given in cases of vomiting should be especially prepared. 
It is always best to use peptonized milk, made by using the pepton- 
izing materials sold by several reliable drug firms. (See Diet, Part 
III.) Lime-water should always be put in the milk if it is not 
peptonized; the small amount usually employed is perfectly useless, 
at least 2 to 3 tablespoonfuls (30.0-45.0) should be placed in each 
glass of milk. 

Another point of importance is the quantity of liquid taken. As 
fast as the patient vomits he is often fed with glasses full of liquid 
by well-meaning friends. Instead of this, he should have only 1 
or 2 teaspoonfuls (4.0-8.0) of milk every hour, half -hour, or fifteen 
minutes, for it is better for him to retain a dram than to take a quart 
and vomit it. Often milk will disagree with the patient, and then 
he may be given with excellent result barley gruel, which has been 
strained, and follow it by 3 grains (0.2) of taka-diastase or a dram 
(4.0) of liquid taka-diastase. In its place strained gruel made from 
wheaten grits, oatmeal, or rice may also be used. 

When the vomiting of pregnancy becomes pernicious in type the 
only cure is emptying of the uterus. Moderate types can be bene- 
fited sometimes by sodium bicarbonate or levulose (see above). In 
the cyclic or toxemic vomiting of childhood, eggs are to be forbidden 
and levulose in solution given by the rectum by the drop method, 
as this state is akin to diabetic coma. (See Diabetes.) So, too, 
it not infrequently happens in the severe diarrheas of early child- 
hood that the body turns upon its fats for energy and oxybutyric 
acid is produced causing so-called acidosis. Usually the child will 
have hurried respirations and a tendency to stupor. Under these 
conditions bicarbonate of sodium should be given freely in solution 
by the mouth and by the Murphy drip. As much as an ounce of 
the soda in twenty-four hours being used in the strength of 2 drams 
to 8 ounces (8.0:350) of water, if possible. Levulose may also be 
used by the rectum, by the drip method, the strength of the solution 
being 15 gram to 1000. A few ounces of this solution going at the 
rate of 10 drops to the minute may be given every eight hours. 
When the condition is urgent, sodium bicarbonate solution should 
be given intravenously in the strength of 4 per cent, or by hypo- 
dermoclysis in the proportion of 2 per cent, and continued until the 
urine is reduced alkaline. If bicarbonate of sodium is used by 
hypodermoclysis the solution must not be boiled, as it will be changed 
into the irritating sodium carbonate and cause a slough. In children 
as young as twelve months as much of the bicarbonate may be used 
as 2 drams (8.0) in twenty-four hours. 



WORMS 959 

WHOOPING-COUGH. 

The remedies recommended for this disease are numerous and 
every one of them is worthless so far as a cure is concerned. Prob- 
ably the best drug of all in the majority of cases is antipyrine. 
Given in the dose of J to 3 grains (0 03-0.2) every five hours accord- 
ing to the age of the child it will nearly always decrease the number 
of paroxysms, but not the severity of each individual attack. (See 
Vaccine Therapy.) 

When the child will submit to it there is little doubt that a solu- 
tion of quinine applied to the pharynx by means of a very fine spray 
will be of service in many cases, and it is very useful when so used, 
as a prophylactic in other children of the family who it is feared 
will be attacked by the same disease, the reason being that the 
specific microorganisms of the disease chiefly exist in the epithelium 
at the root of the tongue. The strength of the solution to be 
employed should be about 1 grain (0.06) to the ounce of water. 

A very useful remedy in some cases is belladonna in the form 
of the tincture, in the dose of 2 minims (0.12) twice a day to a child 
of one or two years. 

Where paroxysms come on so rapidly as to interfere seriously with 
respiration, the child should inhale a whiff of chloroform, the drug 
being poured over the parent's hand, and so relax the spasm. 

Benzine has been found useful in certain cases of whooping-cough. 
It should be lightly sprinkled about the room or on the bed-clothing, 
care being taken that no fire or light is present. 

Bromoform renders good service in some cases. (See article on 
Bromoform for prescription.) 

Often the severity and frequency of the attacks may be modified 
by keeping the patient under a bronchitis-tent or by keeping the air 
of the room moistened by steam. (See Bronchitis.) In other cases 
great benefit arises from keeping the child out of doors. 

WORMS. 

Intestinal parasites may be said to be represented by Ascaris 
lumbricoides or round-worm; Taenia mediocanellata, Taenia solium, 
Taenia saginata, and Bothriocephalus latus, or tape-worm; hook-worm, 
(Necator americanus) ; and, finally, by Oxyuris vermicularis, some- 
times called seat-, pin-, or thread-worm. 

The round-worm, tape-worm, and hook-worm are to be attacked 
by way of the patient's mouth, the seat- worm by way of the anus. 

Whenever a round-, hook-, or tape-worm is to be attacked, the 
patient must be starved for at least twelve to twenty-four hours, in 
order that no food in the intestinal tract may protect the worm from 
the action of the drug. During this time a little milk may be taken, 
and after a night of fasting, before breakfast, the anthelmintic 



960 DISEASES 

must be swallowed. In addition, nearly all of these drugs must 
be followed by purges in order to dislodge the intruder while he is 
paralyzed and has lost his hold; and in many instances it is well to 
have a basin of salt and water ready, so that when a passage occurs 
a rectal injection may be given to wash out the worm in the rectum. 

In the treatment of thread- worms it is necessary to fill the bowel 
thoroughly with soap and water to dislodge the fecal matter and 
expose the worms in the folds of the mucous membrane. 

The drugs which are used against the round- worm are: Spigelia 
in the form of the fluidextract, dose 1 dram (4.0) to a child of two 
or three years, or 2 drams (8.0) to an adult, or, better still, the 
fluidextract of spigelia and senna, dose 2 to 3 drams (8.0-12.0) 
to a child; santonin, dose \ to J grain (0.015-0.03) to a child in the 
form of a troche, made by using the crystals, or as much as 2 to 4 
grains (0.12-0.25) to an adult. (See Santonin.) 

Unless the spigelia is used with senna, it should always be followed 
after from two to four hours by a full dose of castor oil or a saline 
purgative to sweep out the worm, and the same rule applies to all 
the drugs mentioned above. 

The most efficient remedy against the tape-worm is pelletierine, 
the active principle of pomegranate, dose 3 to 5 grains (0.2-0.3) 
in capsule; or pepo, or pumpkin-seeds (2 ounces [60.0]), may be 
resorted to when deprived of their outer coating and rubbed into 
a paste with sugar. Almost, if not quite, as valuable a remedy is 
male fern, or Filix mas, or, as it is officially called, Aspidium. Used 
in the form of the oleoresin {Oleoresina Aspidii), in the dose of \ to 
1 dram (2.0-4.0) to an adult, it should be followed in three or four 
hours by a calomel purge, aided by a saline. Either the calomel or 
the increased amount of bile which is present is apparently peculiarly 
abhorrent to the tape-worm, and a free flow of bile should be made to 
follow the use of all the drugs just named. Aspidium should not be 
followed by castor or other oils, as they increase the absorbability of 
the drug, and so tend to develop symptoms of poisoning. 

For the removal of Uncinaria, thymol may be given in capsule 
and followed by a purge. (See Thymol and- Chenopodium.) 

By far the most useful remedy for seat-worms is quassia used by 
injection. One to 2 ounces (300-60.0) of powdered quassia or 
quassia chips may be made into a decoction with a pint (480 cc) 
of water, and half of this injected into the rectum after it has been 
well cleansed with soap and water. The quassia injection should 
be retained in the bowel for some minutes, and in children this may 
be aided by pressing upon the anal opening the ball of the thumb 
covered by a pad formed from a small folded towel. If this treat- 
ment fails to bring away the worms in three or four trials, either 
there are none present or the bowel was not thoroughly invaded 
by the injection. In some cases the worms infest the colon, and 
large injections sent high up into the bowel are necessary. 



INDEX OF DRUGS AND REMEDIAL 
MEASURES. 



Abbreviations, 63 
Abies excelsa, 448 
Abortifacients, 51 
Abrin, 344 ■ 
Abrus precatorius, 344 
Absolute acetic acid, 70 

alcohol, 78, 86 
Absorption of drugs, 45 
Abstracts, 36 
Acacia, 65 

incompatibles of, 65 

mucilage of, 65 

syrup of, 65 
Acaciae gummi, 65 
A. C. E. mixture, 212, 282 

Billroth's, 212 
Aceta, 36 
Acetanilide, 66 

poisoning by, 68 
Acetanilidum, 66 
Acetate of aluminum, 92 

of ammonium, 96 

of lead, 352 

of potassium, 453 

of sodium, 487 

of zinc, 533 
Acetic acid, 70 
Acetone chloroform, 197 
Acetphenetidin (phenacetin), 71 
Acetphenetidinum, 71 
Acet-theocin-sodium, 513 
Acetum, 70 

cantharidini, 36 

ipecacuanha?, 336 

lobelia?, 357 

opii, 419 

sanguinarise, 476 

scillae, 36, 492 

urginea, 36 
Acetyl-salicylic acid, 140 
Acid, acetic, 70 

acetyl-salicylic, 140 

arsenous, 117, 124 

benzoic, 151 

boric, 155, 156, 547 

camphoric, 180 

carbolic, 431 

cathartic, 482 
61 



Acid, chromic, 218 

chrysophanic, 464 

cinnamic, 230 

citric, 231 

cubebic, 255 

diallylbarbituric, 256 

ecbolic, 269 

ergotic, 269 

gallic, 293 

gentisic, 296 

hydriodic, dilute, 311 

hydrobromic, 163 

hydrochloric, 311 

hydrochloride of quinine, 226 

hydrocyanic, 312 

infusion of cinchona, 229 
of roses, 466 

kinic, 220 

kinotannic, 345 

kinovic, 220 

lactic, bacillus, 346 

lobelic, 356 

lupulinic, 309 

me conic, 409 

methylene-citryl-salicylic, 403 

nitrate of mercury, 380 

nitric, 393 

nitrohydrochloric, 312, 397 

phenic, 431 

phenyl-cinchonic, 141, 230 

phenyl-ethyl-barbituric, 357 

phosphoric, 436 

picric, 441 

polygalic, 482 

prussic, 312 

pyrogallic, 461 

ricinoleic, 189 

salicylic, 468 

santoninic, 476 

sclerotinic, 269 

sodium phosphate, 489 

sulphuric, 501 

tannic, 508 

tartaric, 511 

tartrate of potassium, 453 

toluic, 308 

trichloracetic, 519 

tropic, 308 

valerianic, 528, 529 
Acidum aceticum, 70 

(961) 



962 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Acidum aceticum dilutum, 70 
glaciale, 70 
acetylsalicylicum, 140 
arseniosum, 117, 124 
benzoicum, 150, 151 
boricum, 155, 156 
camphoricum, 180 
carbolicum, 431 

liquef actum, 435 
chromicum, 218 
citricum, 231 
gallicum, 293 
hydriodicum dilutum, 311 
hydrobromicum dilutum, 163 
hydrochloricum, 311 

dilutum, 312 
hydrocyanicum, 312 

dilutum, 312 
nitricum, 393 
dilutum, 395 
fumans, 395 
nitrohydrochloricum, 312, 397 

dilutum, 312, 397 
phenyl cinchonicum, 141, 230 
phosphoricum concentratum, 436 

dilutum, 436 
picricum, 441 
salicylicum, 468 
sulphuricum, 501 

aromaticum, 502 
dilutum, 502 
tarmicum, 508 
tartaricum, 511 
trichlor aceticum, 519 
valerianicum, 529 
Acoine, 72 
Aconine, 73 
Aconite, 72 

liniment, 76 
poisoning by, 74 
Aconitina, 76 
Aconitine, 73, 76 
ointment, 76 
oleate, 75 
Aconitum Napellus, 72 
Acriflavine, 546 

Action of drugs, cumulative, 47 
direct, 30 
duration of, 46 
idiosyncrasy to, 44, 49 
indirect, 30 
modes of, 20 
Acupuncture, 537 
Adalin, 76 

Adeps benzoatus, 151 
benzoinatus, 151 
lanae, 347 

hydrosus, 347 
Administering drugs, modes of, 31 
Adonidin, 77 
Adonis vernalis, 77 
Adrenalin, 503 
Adrenalinum, 503 
.Ether, 272 

fortior, 272 



Mther purificatus, 272 
JEthylcarbonate of quinine, 290 
iEthylis bromidum, 283 

chloridum, 284 

salicylas, 467 
iEthylmorphinae hydrochloridum, 267 
Agar, 77 
Agaric, 77 
Agaricin, 77 
Alcohol, 78, 86 

absolutum, 78, 86 

administration of, 85 

amylic, 78 

contraindications to, 86 

dehydratum, 78, 86 

dilutum, 78, 86 

ethylicum, 78 

phenylic, 431 
Alcoholism, acute, 81 

differentiation of,_ from apo- 
plexy, 82 ' 
from opium-poisoning, 82 

chronic, 84 

differentiation of, from paretic 
dementia, 85 
Aldehyde, formic, 291 
Ale, 86 
Alkaloids, 36 
Allis ether inhaler, 279 
Allium, 87 

juice, 87 

sativum, 87 

syrup of, 87 
Allspice, 447 
Almond bread, 87, 657 

milk, 658 
Almonds, 87 

bitter, 87, 88 

sweet, 87 
Aloe, 88 

Chinensis, 88 

Perryi, 88 

vera, 88 
Aloes, 88 

compound decoction of, 90 

contraindications to, 90 

glycerole of, 90 
Aloin, 88, 90 
Aloinum, 88, 90 
Alpha-eucaine, 287 
Alteratives, 51, 55 
Alum, 90 

acetate solution, 91 

ammonio-ferric, 338 
Alumen, 90 

exsiccatum, 91 

purificatum, 90 
Alumini acetas, 92 
Aluminum acetate, 92 
Alypin, 92 
Amber, 92 

American wormseed, 191 
Amido-azo-toluene-azo-beta-naphthol, 

478 
Ammonia, 93 



INDEX OF DRUGS AND REMEDIAL MEASURES 



963 



Ammonia liniment, 95 
Ammonia-water, 95 

stronger, 95 
Ammoniac, 95 
Ammoniacum, 95 
Ammoniated glycyrrhizin, 355 

liniment of camphor, 179 

mercury, 371 

tincture of ergot, 271 
of guaiac, 301 
of opium, 419 
of quinine, 227 
of valerian, 529 
Ammonii acetas, 96 

benzoas, 96 

bromidum, 96 

carbonas, 97 

chloridum, 98 

iodidum, 99 

phosphas, 100 

valeras, 100, 529 
Ammonio-ferric alum, 338 
Ammonium, 95 

ichthyol, 318 

sulphate, 100 
Amygdala dulcis, 87 
Amygdalin, 87, 461 
Amyl nitrite, 100 
Amylic alcohol, 78 
Amylis nitris, 100 
Amvlopsin, 424 
Amylum, 493 
Anaphrodisiacs, 51 
Anaphylaxis, 755 
Anesthesia by infiltration, 235, 236 

by rectal injection of ether, 282 

insufflation, 281 

nitrous oxide and oxygen, 400 

scopolamine-morphine, 480 

spinal, method of inducing, 458 
Anesthetics, 51, 55 
Antacids, 51, 55 
Anthelmintics, 51, 55 
Anthrarobin, 102 
Antiarthritics, 51 
Antidiphtheritic globulin, 550 

serum, 549 
Antidotum arsenici, 128, 340, 360 
Antidvsenteric serum, 551 
Antifebrin, 66 
Antigonococcic serum, 551 
Antihydrotics, 51 
Antimalarials, 55 
Antimeningitis serum, 552 
Antimonial powder, 103, 106 
Antimonii et potassii tartras, 103, 106 
oxidum, 103 
sulphidum, 103 

purificatum, 103 
Antimonium nigrum purificatum, 103 
sulphuratum, 103 
tartaratum, 103 
Antimony, 103 

compound pill of, 106 
ointment of, 106 



Antiperiodics, 51, 55 
Antiphlogistics, 51 
Antipneumococcic serum, 553 
Antipoliomyelitis serum, 554 
Antipyretics, 56 
Antipyrina, 108 
Antipyrine, 108 
Antiseptics, 55, 538 
Antispasmodics, 56 
Antistreptococcus serum, 554 
Antitetanic serum, 554 
Antithyroidin, 519 
Antitoxin, 548 

for diphtheria, 549 
for dysentery, 551 
for gonorrhea, 551 
for meningitis, 552 
for pneumonia, 553 
for poliomyelitis, 554 
for streptococcic infections, 554 
for tetanus, 554 
Antuitrin, 450 
Aphrodisiacs, 51 
Apiol, 113 
Apis mellifica, 308 
Apocynum, 114 

androsaemifolium, 114 
cannabinum, 114 
Apomorphinae hydrochloridum, 114, 116 
Apomorphine, 114 
Apothecaries' measure, 38 

weight, 38 
Apothesine, 116 

Apparatus for intravenous arsphena- 
mine injections, 135 
nitrous oxide-oxygen-ether, 401 
Aqua ammoniae, 95 
fortior, 95 
amygalae amarae, 88 
camphorae, 178 
chloroformi, 213, 218 
cinnamomi, 230 
creosoti, 254 
hamamelidis, 304 
menthae piperitae, 427 
pimentae, 447 
rosae, 466 
Aquae, 36 
Arbutin, 528 

Arctostaphylos uva ursi, 528 
Argent i nitras, 390 
fusus, 390 
mitigatus, 393 
Argyria, 391 
Argyrol, 116 
Aristol, 515 
Aristolochia reticulata, 

serpent aria, 483 
Aristolochin, 483 
Arnica, 117 

montana, 117 
Aromatic chalk powder 
fluidextract. 230 

of cascara sagrada, 1SS 
mixture of iron, 338 



483 



171 



964 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Aromatic powder, 188, 230 

spirit of ammonia, 95 

sulphuric acid, 502 

syrup of cascara, 188 
of rhubarb, 465 

tincture of rhubarb, 465 
Arsenate of copper, 117 

of iron, 338 

of sodium, 117, 125 
exsiccated, 125 
Arseni iodidum, 125 

trioxidum, 117, 124 
Arsenic, 117 

trioxide, 117, 124 
Arsenite of potassium, 117 
Arsenous acid, 117, 124 
Arsenum, 117 
Arsphenamine, 129 

contraindications to, 138 

provocative dose of, 132 

silver, 484 

sodium, 139 

untoward effects of, 137 
Artemesia pauciflora, 476 
Artificial milk, 658 
Asafetida, 139 
Asafcetida, 139 
. Asagraea officinalis, 529 
Aspidium, 140 

filix-mas, 140 
Aspirin, 140 
Astringents, 51, 56 

mineral, 56 

vegetable, 56 
Atomization, 35 
Atophan, 141 
Atropa belladonna, 143 
Atropina, 143 
Atropinae sulphas, 143, 149 
Atropine, 143 
Auranine, 383 

Auri et sodii chloridum, 300 
Avoirdupois weight, 38 
Azedarach, 141 

decoction of, 142 

fluidextract of, 142 



B 

Bacillen emulsion tuberculin, 521 
Bacillus bulgaricus, 347 

lactic acid, 346 
Balsam of copaiba, 248 

of Peru, 142 
Balsamum Peruvianum, 142 
Barbital, 142 

sodium, 142 
Barbitonum, 142 
Barley-water, 656 
Barosma betulina, 165 
Basham's mixture, 337, 338 
Bath, Brand, 570 

cabinet, electric, 594 

cold, 563 

Russian, 591, 595 



Bath, stretcher, 571 

Turkish, 591 
Bearberry, 528 
' Beechwood creosote, 251 
Beef essence, 656 

peptonized, 651 
Beef- tea, 655 
Beer, 86 
Belladonna, 143 

contraindications to, 149 

leaves, 143 

liniment, 149 

ointment, 149 

plaster, 149 

poisoning by, 146 

root, 143 

suppositories, 149 
Belladonnas folia, 143 

radix, 143 
Benzaconine, 73 
Benzamine lactate, 288 
Benzoate of ammonium, 96 

benzyl, 151 
Benzoated lard, 151 
Benzoic acid, 150 
Benzoin, 150 
j Benzoinated lard, 151 
J Benzoinum, 150 
Benzonaphthol, 151 
Benzosulphanidum (saccharin), 466 
i Benzoyl monohydrochloride, 92 
' Benzyl benzoate, 151 
Berberine, 173, 310 
Beta-eucaine hydrochloride, 287 
I Beta-eucainse hydrochloridum, 287 

lactate, 288 
Beta-naphthol, 151 
Beta-naphthol-bismuth, 152 
Bicarbonate of potassium, 453 

of sodium, 487 
Bichloride of mercury, 372 

as an antiseptic, 538 
Bier's hyperemic treatment, 556 
Billroth's A. C. E. mixture, 212 
Bimuriate of quinine and urea, 228 
Biniodide of mercury, 375 
Binoxide of manganese, 362 
Bismuth, 152 

and ammonium citrate, 152 

betanaphtol, 152 

carbonate, 153 

hydroxide, 154 

milk of, 154 

salicylate, 155 

subcarbonate, 153 

subgallate, 152 

subnitrate, 153 

subsalicylate, 155 
Bismuthi betanaphtholas, 152 

carbonas, 153 

et ammonii citras, 152 

salicylas, 155 

subcarbonas, 153 

subgallas, 152 

subnitras, 153 



INDEX OF DRUGS AND REMEDIAL MEASURES 



965 



Bismuthi subsalicylas, 155 
Bisulphate of quinine, 226 
Bitartrate of potassium, 453 
Bitter almonds, 87 

wine of iron, 343 
Bitters, 52 
Black cohosh, 219 

draught, 483 

drop, 419 

ginger, 297 

mustard, 386 

oxide of manganese, 362 

pepper, 426 

snake-root, 219 

wash, 375 
Blaud's pill, 339 
Bleeding, 644 

Blistering collodion, 184, 245 
Blisters, 577 

figures showing areas to apply, 577, 
578, 580 

flying, 579 
Blood-root, 475 
Blue ointment, 379 

pill, 375 
Blue-gum tree, 288 
Blue-mass, 375 
Bone-marrow, 298 
Boneset, 289 
Bonjean's ergotin, 271 
Borate of sodium, 155 
Borated lint, 156 
Borax, 155 

purificatum, 155 
Boric acid, 155, 156, 547 
Boroglycerin, glycerite of, 300 
Bouillon filtrate tuberculin, 521 
Bran bread, 657 
Brand bath, 570 
Brandy, 86 
Brassica nigra, 386 
Bread, almond, for diabetics, 87, 657 

bran, for diabetics, 657 
Bromdiethylacetylcarbamide, 76 
Brometone, 157 
Bromide of ammonium, 96 

of calcium, 162, 169 

of ethyl, 283 

of lithium, 163, 356 

of potassium, 157 

of sodium, 163 

of strontium, 495 
Bromides, 157 

contraindications to, 162 

poisoning by, 161 
Bromine, 163 
Bromism, 162 
Bromoform, 164 
Brqmoformum, 164 
Bromum, 163 
Bronchitis, moist air inhalations in, 35 

tents, 598, 608 
Broom, 479 
Brown mixture, 355 
Brucine, 404 



Bryonia, 164 

alba, 164 

dioica, 164 
Bryony, 164 
Buchu, 165 

folia, 165 
Bulgarian lactic acid bacillus, 347 
Burgundy pitch, 448 
Buttermilk and starch, 649 
Butyl chloral hydras, 254 



Cacodylate of iron, 339 

of sodium, 487 
Cactus grandiflorus, 166 

fluidextract of, 166 
tincture of, 166 
Caffea, 166 

Arabica, 166 
Caffeina, 166 

citrata, 167 

effervescens, 167 
Caffeinae citras, 167 

effervescens, 167 

sodio-benzoas, 169 
Caffeine, 166, 167 

citrated, 167 
Cajuput oil, 169 
Calabar bean, 439 
Calabarine, 440 
Calamine, 534 
Calcii bromidum, 162, 169 

carbonas prsecipitatus, 170 

chloridum, 170, 171 

hydras, 176 

hypophosphis, 170, 172 

phosphas, 170 

prsecipitatus, 170 

sulphidum crudum, 176 
Calcined magnesia, 359 
Calcium, 169 

bromide, 162, 169 

chloride, 170, 171 

glycerophosphate, 170 

hydroxide, 174 

hypochlorite, 176 

hypophosphite, 170, 171 

lactate, 170, 171 

lactophosphate, 172 

oxide, 173 

phosphate, 170, 172 

sulphate, 170, 173 
California buckthorn, 188 
Calomel, 375 

ointment, 378 
Calomeletts, 376 
Calumba, 173 
Calumbse radix, 173 
Calumbic acid, 173 
Calumbine, 173 
Calx, 173 

chlorinata, 174 

sulphurata, 176 



966 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Camphor, 176 

compound tincture of, 179 
liniment, 178 
mixture, Hope's, 309 
monobromate, 179 
spirit of, 178 
Camphor-water, 178 
C amphora, 176 

monobromata, 179 
Camphorated alcohol, 178 
oil, 178 

tincture of opium, 418 
Camphoric acid, 180 
Canada pitch, 448 

plaster, 448 
Cannabinol, 180 
Cannabis, 180 
indica, 180 
sativa, 180 
Cantharidal cerate, 184 
collodion, 184, 245 
Cantharidin, 183 
Cantharis, 182 

vesicatoria, 182 
Capsici fructus, 184 
Capsicine, 184 
Capsicum, 184 

fastigiatum, 184 
fruit, 184 
plaster, 186 
Carbo ligni, 186 
Carbolic acid, 431 

as an antiseptic, 539 
ointment, 435 
poisoning by, 432 
Carbon, 186 

Carbon-dioxide snow, 559 
Carbonate of ammonium, 97 
of bismuth, 153 
of calcium, 170 
of creosote, 254 
of guaiacol, 304 
of iron, 337, 339 
of lead, 352 
of lithium, 356 
of magnesium, 358 
of potassium, 454 
of zinc, 534 
Cardamom, 187 

seed, 187 
Cardamomi semen, 187 
Cardiac sedatives, 52, 56 

stimulants, 52, 56 
Carminative powder, 230 
Carminatives, 52 
Carolina pink, 491 
Carron oil, 174, 291 
Caryophyllum, 231 
Caryophyllus, 231 
Cascara cordial, 188 
evacuant, 188 
sagrada, 188 
Casein milk, 649 
Cassia acutifolia, 482 
angustifolia, 482 



Cassia Carica papaya, 425 
Castile soap, 485 
Castor oil, 188 
Cataphoresis, 35 
Cataplasma carbonis, 186 

kaolini, 345 
Cataplasms, 36 
Cathartic acid, 482 
Cathartics, 52, 58 
Cat's-hair, 289 
Caustic potash, 457 

soda, 489 
Caustics, 577 
Cautery, 579 
Cayenne pepper, 184 
Cephaeline, 333 
Cephselis ipecacuanha, 333 
Cerates, 36 
Ceratum cantharidis, 184 

plumbi subacetatis, 353 

resinse, 462 

compositum, 462 
Cerebral extracts, 298 
Cerii oxalas, 191 
Cerium oxalate, 191 
Chalk, 170 

mixture, 170 
Chamber inhaler, 606 
Champagne, extra dry, 86 
Charcoal, 186 

poultice, 186 
Charta potassii nitratis, 458 

sinapis, 387 
Chartae, 36 
Chenopodium, 191 

ambrosioides, 191 

oil of, 191 
Chinoidinum, 229 
Chloral, 192 

formamide, 196 

formamidum, 196 

hydras, 192 

hydrated, 192 

poisoning by, 193 
chronic, 195 
Chloralum hydratum, 192 
Chloramine, 196 
Chloramine-T, 546 
Chlorate of potassium, 454 

troches of, 456 
Chlorcosane, 544 
Chloretone, 197 
Chloride of ammonium, 98 

of calcium, 170, 171 

of ethyl, 284 

of gold and sodium, 300 

of iron, 337, 339 

of mercury, corrosive, 372 
mild, 375 

of methyl, 384 

of methylene, 384 

methylthionine, 384 

of sodium, 488 

of zinc, 534 

as an antiseptic, 547 



INDEX OF DRUGS AND REMEDIAL MEASURES 



967 



Chlorinated lime, 174 

as a disinfectant, 585 
Chlorine gas, 176 
Chlorobrom, 197 
Chlorodyne, 198 
Chloroform, 199 

contraindications to, 213 

inhaler, Esmarch's, 210 

Krohne and Seseman's modifi- 
cations of Lawrie's, 212 
Lawrie's, 211 

liniment, 218 

spirit of, 213, 218 
Chloroform-water, 213, 218 
Chloroformum, 199 
Cholagogues, 52 

Chondodendron tomentosum, 426 
Chromic acid, 218 
Chromii trioxidi, 218 
Chromium trioxide, 218 
Chrysarobin, 218 

ointment, 218 
Chrysarobinum, 218 
Chrysophanic acid, 464 
Cimicifuga, 219 

racemosa, 219 
Cinchona, 220 

calisaya, 220 

ledgeriana, 220 

officinalis, 220 

rubra, 220 

rubrae cortex, 220 

succirubra, 220 
Cinchonicine, 220 
Cinchonidinae sulphas, 229 
Cinchonidine, 220 

sulphate, 229 
Cinchoninae sulphas, 229 
Cinchonine, 220 

sulphate, 229 
Cinchophen, 141 
Cinnamic acid, 230 
Cinnamomi cortex, 230 
Cinnamomum camphora, 176 

saigonicum, 230 

zeylanicum, 230 
Cinnamon, 230 
Cinnamon-water, 230 
Citrate, bismuth and ammonium, 152 

of iron, 340 

and ammonium, 340 
and quinine, 340 
and strychnine, 340 

of hthium, 356 

of magnesium, 359 

of potassium, 456 

of sodium, 488 
Citrated caffeine, 167 
Citric acid, 231 
Citrine ointment, 380 
Citrophen, 72 
Citrullus colocynthis, 245 
Clarified honey, 309 
Classification of drugs, 55 
Claviceps purpura, 269 



Climate, influence of, on dosage, 50 

Climates, 624 

Clove, 231 

Clyster, 33 

Cobalto-nitric of potassium, 395 

Coca, 232 

Cocae folia, 232 

Cocaina, 232 

Cocainae hydrochloridum, 232, 234, 237 

Cocaine, 232 

habit, 237 

hydrochloride, 232, 234 

oleate of, 234 

untoward effects of, 238 
Cod-liver oil, 239 
Codeina, 238, 409 
Codeinae phosphas, 238 

sulphas, 238 
Codeine, 238, 409 

phosphate, 238 

sulphate, 238 
Coffee, 166 
Colchiceine, 242 
Colchici cormus, 242 

semen, 242 

semina, 242 
Colchicina, 242, 244 
Colchicine, 242, 244 
Colchicum, 242 

autumnale, 242 

corm, 242 

seed, 242 
Cold bath, 563 

as a remedy, 560 

cream, 466 

in fevers, 566 
Collodion, 244 

cantharidal, 184, 245 

flexible, 244 

iodol, 332 

styptic, 244, 509 
Collodium, 244 

cantharidatum, 184, 245 

flexile, 244 

stypticum, 244, 509 

vesicans, 184, 245 
Colocynth, 245 
Colocynthidis pulpa, 245 
I Colocynthine, 245 
Colocynthis, 245 
Cologne-water, 86 
Columba, 173 
Columbine, 173 
Columbo, 173 

Combination of drugs for joint effect, 47 
Commercial oxide of zinc, 534 
Commiphora myrrhae, 388 
Compound cathartic pill, 245 

cerate of resin, 462 

decoction of aloes, 90 

effervescing powder, 481 

extract of colocynth, 245, 478 

fluidextract of sarsaparilla, 477 

infusion of gentian, 297 
of senna, 363, 483 



968 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Compound liniment of mustard, 388 
mixture of iron, 339 
of licorice, 355 
of senna, 483 
pill of antimony, 106 
of calomel, 378 
of colocynth, 245 
of galbanum, 140 
of rhubarb, 464 
of scammony, 478 
of soap, 419 
of squill, 492 
powder of almonds, 88 
of catechu, 294 
of chalk, 170 
of cinnamon, 230 
of elaterin, 269 
of ipecac, 336, 419 
of jalap, 343 
of kino, 346 
of liquorice, 355, 483 
of morphine, 421 
of opium, 419 
of rhubarb, 464 
of scammony, 478 
solution of cresol, 358 

of iodine, 329 
spirit of ether, 306 

of juniper, 86, 345 
suppositories of lead, 352 
syrup of sarsaparilla, 477 

of squill, 106, 492 
tincture of benzoin, 151 
of camphor, 179, 418 
of cardamom, 187 
of chloroform and morphine, 

218, 421 
of cinchona, 229, 483 
of gambir, 294 
of gentian, 297 
of rhubarb, 465 
of senna, 483 
Condurango, 246 

bianco, 246 
Confectio piperis, 426 
rosse, 309, 466 

gallicae, 466 
sennse, 482, 508 
sulphuris, 501 
Confections, 36 
Coniine, 246 

hydrobromide, 247 
Conium, 246 

maculatum, 246 
Conserves, 36 

Contraindications for drugs, 50 
Convallamarin, 248 
Convallaria, 247 
^najalis, 247 
Convolvulin, 343 
Convolvulus scammonia, 478 
Cool sponging, 567 
Coordinated movements for treating 

locomotor ataxia and myelitis, 575 
Copaiba, 248 



Copper, 248 

Cornutine, 270 

Corpus luteum, 250, 298 

Corrosive mercuric chloride, 372 

sublimate, 372, 585 
Cosmoline, 430 
Cotarnine, 251 

hydrochloride, 251 
Counterirritants, 52, 56 
Counterirritation, 577 
Coxe's hive syrup, 106, 482, 492 
Cream of tartar, 453 
Creolin, 251, 546 

as an antiseptic, 546 
Creosotal, 254 
Creosote, 251 

carbonate, 254 

inhaler, Yeo's, 252, 609 

mixture, 254 

ointment, 254 
Creosote-water, 254 
Creosotum, 251 
Creta prseparata, 170 
Croton chloral, 254 

oil, 254 

liniment, 255 

tiglium, 254 
Croup kettle, 607 
Cubeba, 255 

fructus, 255 
Cubebic acid, 255 
Cubebin, 255 
Cubebs, 255 
Cucurbita pepo, 426 
Cumulative action of drugs, 47 
Cupping, 582 
Cupri sulphas, 248 
Cuprum, 248 
Cups, dry, 582 

applied, 582 

wet, 582 
Curds and whey, 429 
Cyanide of potassium, 457 
Cytisus scoparius, 479 



Dakin's fluid as an antiseptic, 541 

Dandelion, 510 

Datura stramonium, 494 

Daturine, 494 

Deadly nightshade, 143 

Decoction of azedarach, 142 

of condurango, 246 

of euphorbia pilulifera, 290 
Decoctions, 36 
Decoctum aloes compositum, 90 

granati corticis, 452 

hsematoxyli, 304 

scoparii, 480 
Definition of drugs, 50 

of therapeutics, 17 
Demulcents, 52 
Denison's resistance inhaler, 605 



INDEX OF DRUGS AND REMEDIAL MEASURES 



909 



Deny's tuberculin, 521 
Deodorized opium, 418 
Dermatol, 152 
Deshler's salve, 462 

Diacetylmorphinse hydrochloridum, 305 
Diachylon, 353 
Dial, 256 

Diallylbarbituric acid, 256 
Diallylmalonylurea, 256 
Diamorphinse hydrochloridum, 305 
Diaphoretics, 53, 56 
Diastase, 256 
Diastasum, 256 
Dichloramine-T, 543 
Dichlormethane, 384 
Diet for child one year old, 654 
seven years old, 654 
six to twelve months old, 655 
two years old, 654 

importance of, in disease, 19 

lists, 654 
Dietetic treatment, importance of, 60 
Diethylmalonylurea, 142 
Diethyl-sulphon-dimethyl methane, 498 
Digalen, 266 
Digestants, 56 
Digested gruel, 653 
Digifoline, 266 
Digipuratum, 266 
Digitalein, 257, 265 
Digitalin, 257, 264, 265 
Digitalis, 257 

contraindications to, 263 

folia, 257, 264 

poisoning by, 263 

purpurea, 257 
Digitalone, 266 
Digitin, 257 
Digitonin, 257 
Digitoxin, 257 

Dihydrochloride of dioxydiamidoarseno- 
benzol; 129 

of quinine, 226 
Dilute acetic acid, 70 

alcohol, 78, 86 

hydriodic acid, 311 

hydrobromic acid, 163 

hydrochloric acid, 312 

hydrocyanic acid, 312 

nitrate of silver, 393 

nitric acid, 395 

nitrohydrochloric acid, 312, 397 

phosphoric acid, 436 

solution of subacetate of lead, 353 

sulphuric acid, 502 
Dionin, 267 
Dioxydiamidoarsenobenzoldihvdrochlo- 

ride, 129 
Diphtheria antitoxin, 549 
Direct action of drugs, 30 
Disease, elimination in, 19 

food in, 19 

relief of symptoms in, 20 

sleep in, 20 

treatment of, factors in, 18 



Disinfectants, 56, 583-585 
Disinfection, 583 

Distilled extract of hamamelis, 304 
Dithymol diiodide, 515 
Diuretics, 53, 57 
Diuretin, 486 
Dobell's solution, 155 
Donovan's solution, 125 
Dorema ammoniacum, 95 
Dosage, 41 

according to weight, 44 

by the rectum, 45 

hypodermic, 45 

rules of, 44, 45 

Young's rule of, 45 
Dose, "provocative," of arsphenamine 

in syphilitics, 132 
Dover's powder, 336, 419 
Dried alum, 91 

corpus luteum, 298 

sulphate of iron, 343 

suprarenal gland, 503, 506 

thvroid gland, 516 
Drip, Murphy, 888 

rectal, 888 

sheet, 565 
Drop method of giving ether, 279 

size of a, 42, 45 
Drugs, absorption of, 45 

physical factors governing, 46 
physiological factors govern- 
ing, 45 

classification of, 55 

combination of, for joint effect, 47 

cumulative action of, 47 

direct and indirect action of, 30 

duration of action, 46 

idiosyncrasy to action of, 44, 47 

indications and contraindications 
for, 50 

modes of action of, 20 
of administering, 31 

strength and reliability of, 48 
Dry cups, 582 

applied, 582 

heat,_ 598 
Dryopteris filix mas, 140 
Duboisia myoporoides, 267 
Duboisine, 267 

sulphate, 267 
Duration of action of drugs, 47 



E 



268 



I Ecballium elaterium, 
i Ecbolic acid, 269 
' Ecgonine, 232 

Effervescent citrate of magnesium, 359 
of potassium, 456 

citrated caffeine, 167 

phosphate of sodium, 489 

sulphate of sodium, 490 
Effervescing draught, 456 

powder, 481 



970 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Effervescing sulphate of magnesium 
361 
of sodium, 489 
Egg-flip, 87 
Egg-nog, 85 
Elaterin, 268 
Elaterinum, 268 
Elaterium, 268 
Electric bath cabinet, 594 
Electuaries, 36 
Elettaria repens, 187 
Elimination in disease, 19 
Eliminators, 53, 57 
Elixir of ammonium valerate, 100 

ferri, quininae, et strychninse phos- 
phatum, 341 

glycyrrhizae, 355 

phosphori, 439 

roborans, 229 

terpini hydratis cum heroina, 512 
Elixirs, 36 
Emetics, 53, 57 

contraindications to, 53 

direct, 53, 57 

peripheral, 53, 57 
Emetinae hydrochloridum, 333, 336 
Emetine, 333 
Emmenagogues, 53, 57 

direct, 53, 57 

indirect, 53, 57 
Emplastra, 36 
Emplastrum arnicse, 117 

asafcetidae, 139 

belladonnae, 149 

cantharidini, 184 

cantharidis, 184 

capsici, 186 

ferri, 343 

hydrargyri, 380 

menthol, 429 

picis, 448 

burgundicae, 448 
canadensis, 448 
cantharidatum, 184, 448 

plumbi, 353 
iodidi, 352 

saponis, 486 

sinapis, 387 
Emulsin, 87, 460 
Emulsion of almonds, 88 

of asafcetida, 139 

of cod-liver oil, 242 

of sweet almonds, 88 

of turpentine, 527 
Emulsions, 36 
Emulsum amygdalae, 88 

asafcetidae, 139 

olei morrhuae, 242 
terebinthinae, 527 
Endermic medication, 35 
Enema, 33 

nutrient, 33 

peptonized, 652 
Enteroclysis, 586 
Epispastics, 56, 577 



lErgone, 271 
Ergot, 269 

ammoniated tincture of, 271 

aseptic, 271 
Ergota, 269 
Ergotic acid, 269 
Ergotin, 271 

Bonjean's, 271 
Ergotinum, 271 
Ergotoxin, 269 
Erigeron, 272 

canadense, 272 
Erythrol tetranitrate, 397 
Erythroxylon, 232 

coca, 232 
Escharotics, 56, 577 
Eserine, 440, 441 

Esmarch's chloroform inhaler, 210 
Ether, 272 

contraindications to, 283 

"drop method" of giving, 279 

inhaler, Allis, 279 

intratracheal insufflation of, 281 

rectal administration of, for anes- 
thesia, 282 

untoward effects of, 276 
Ethyl alcohol, 78 

bromide, 283 

chloride, 284 
inhaler, 286 

morphine hydrochloride, 267 

salicylate, 473 
Ethylate of sodium, 488 
Ethylhydrocuprein hydrochloride, 287 
Eucaine hydrochloride, 287 

lactate, 288 
Eucalyptol, 288 
Eucalyptus, 288 

globulus, 288 
Euformol, 292 
Eugenia aromatica, 231 
Eugenol, 232 
Euonymi cortex, 289 
Euonymin, 289 
Euonymus, 289 

atropurpura, 289 
Eupatorium, 289 

perfoliatum, 289 
Euphorbia piluifera, 289 
Euphthalmin, 290 
Euquinine, 290 
Evan's pocket inhaler, 609 
Exercises for treating locomotor ataxia 

and myelitis, 575 
Exogonium purga, 343 
Expectorants, 54, 57 
sedative, 54, 57 
stimulating, 54, 57 
Exsiccated ferrous sulphate, 343 
sodium arsenate, 125 
phosphate, 489 
Extract, ovarian, 298, 421 
Extracts, 36 

glandular, 297 
Extractum aconiti, 76 



INDEX OF DRUGS AND REMEDIAL MEASURES 



971 



Extractum belladonnae alcoholicum, 
149 

foliorum, 149 

liquidum, 149 

siccum, 149 
cannabis, 182 
cascarae sagradae, 188 
liquidum, 188 
siccum, 188 
cimicifugae, 219 
cinchonas, 229 

liquidum, 229 
cocae liquidum, 237 
colchici, 244 

cormi, 243 
colocynthidis, 245 

compositum, 245, 478 
conii, 247 
ergotae, 271 

liquidum, 271 
euonymi, 289 
felis bovis, 422 
filicis liquidum, 140 
gelsemii, 296 
gentianae, 297 
glycyrrhizae, 355 

liquidum, 355 

purum, 355 
haematoxyli, 304 
hamamelidis liquidum, 305 
hydrastis, 311 

liquidum, 310 
hyoscyami, 317 
ipecacuanhae liquidum, 336 
jaborandi liquidum, 446 
jalapae, 344 
leptandrae, 354 
nucis vomicae, 407 

liquidum, 407 
siccum, 407 
opii, 418 

liquidum, 419 

siccum, 418 
pareirae liquidum, 426 
physostigmatis, 441 
pilocarpi liquidum, 446 
podophylii, 451 
rhei, 464 

sarcae liquidum, 477 
stramonii, 494 
strophanthi, 497 
sumbul, 502 
taraxci, 510 
uva ursi, 528 



Factors in treatment of disease, 18 
Fagus ferruginea, 251 

silvatica, 251 
Feeding the sick, 646 
Fel bovinum purificatum, 422 
Ferri arsenas, 338 

cacodylas, 339 



Ferri carbonas saccharatus, 337, 339 

>chloridum, 337, 339 

citras, 340 

et ammonii citras, 340 
sulphas, 337, 338 

et quininae citras, 340 
solubilis, 340 

et strychninae citras, 340 

hydroxidum, 340 

cum magnesii oxido, 128, 340, 
360 

iodidum saccharatum, 341 

lactas, 341 

phosphas, 341 

saccharatus, 341 
solubilis, 341 

pyrophosphas solubilis, 341 

reductum, 337, 341 

subsulphas, 337 

sulphas, 337, 343 
exsiccatus, 343 
granulatus, 343 

valeras, 529 
Ferric chloride, 337, 339 

hydroxide, 340 

phosphate, 341 
Ferrous arsenate, 338 

carbonate, saccharated, 337, 339 

iodide, saccharated, 341 

lactate, 341 

sulphate, 337, 342 
Ferrum, 336 

reductum, 337, 341 
Ferula fcetida, 139 
Fevers, cold in, 566 
Fibrolysin, 514 
Filix mas, 140 
Flaxseed, 290 

meal, 291 

oil, 290 

poultice, 291 

tea, 291 
Fleabane, 272 

Fleming's tincture of aconite, 76 
Flexible collodion, 244 
Flowers of sulphur, 500 
Fluidextract of apocynum, 114 

of azedarach, 142 

of cactus grandiflorus, 166 

of condurango, 246 

of convallaria, 248 

of cubeb, 255 

of euonymus, 289 

of eupatorium, 289 

of euphorbia pilulifera, 290 

of hgematoxylon, 304 

of hops, 309 

of quassia, 462 

of rhus aromatica, 465 

of sanguinaria, 475 

of savine, 478 

of solanum carolinense, 490 

of wild cherry, 461 
Fluidextracts, 36 
Fluidextractum aconiti, 76 



972 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Fluidextractum aromaticum, 230 

belladonnae radicis, 149 

buchu, 166 

calumbae, 173 

cannabis, 182 

capsici, 186 

cascarae sagradai, 188 

aromaticum, 188 

cimicifugae, 219 

cinchonae, 229 

colchici seminis, 244 

digitalis, 264 

ergotae, 271 

eucalypti, 289 

gelsemii, 296 

gentianae, 296 

glycyrrhizae, 355 

granati, 452 

grindeliae, 301 

hydrastis, 310 

hyoscyami, 317 

ipecacuanhas, 336 

leptandrae, 354 

lobelias, 357 

nucis vomicae, 407 

pareirae, 426 

pilocarpi, 446 

podophylli, 451 

rhei, 465 

rosae, 466 

sarsaparillae, 477 

compositum, 477 

scillae, 492 

senegae, 482 

sennae, 482 

spigeliae, 491 

et sennae, 491 

stillingiae, 493 

sumbul, 502 

taraxaci, 511 

uva ursi, 528 

veratri viride, 531 

zingiberis, 297 
Flying blister, 579 
Food in disease, 19 

materials, 646 
Foods for the sick, 646 
Formaldehyde, 291, 540, 584,- 585 

solution, 292 
Formic aldehyde, 291 
Formidine, 291 
Fowler's solution, 124 
Foxglove, 257 
Fraxinus ornus, 362 
Frazier-Lentz hot-air apparatus, 597 
Fumigation, 31 

lamp for mercurial, 366 
Fusel oil, 78 



Gadus morrhua, 239 
Galla, 294 
Gallic acid, 293 

ointment, 293 



j Gambir, 294 

! Garlic, 87 

! Gaultheria, 295 

procumbens, 295 
1 Gavage, 589 

method of employing, 589 
Gelsemii radix, 295 
Gelsemine, 295, 296 
Gelseminine, 295 
Gelsemium, 295 

poisoning by, 296 

sempevirens, 295 
General therapeutic considerations, 17 
Gentian, 296 
Gentiana, 296 

lute a, 296 
Gentianae radix, 296 
Gentianine, 296 
Gentisic acid, 296 
German chamomile, 363 

soft soap, 485 
Germicides, 583-585 
Germs, mode of destroying, 583-585 
Gin, 86, 345 
Ginger, 297 
Glacial acetic acid, 70 
Gland, pituitary, 448 

parathyroid, 426 

suprarenal, 503 

thymus, 516 

thyroid, 516 
Glandular extracts, 297 
Glaseptic nebulizer, 610 
Glauber's salt, 490 
Globulin, antidiphtheritic, 550 
Glonoin, 396 
Glusidum, 466 
Glycerin, 298 

suppositories, 299 
Glycerins, 36 
Glycerinum, 299 

acidi borici, 300 

carbolici, 300, 435 
tannici, 300, 509 

aluminis, 92, 300 

amyli, 300 

boracis, 300 

pepsini, 300, 429 

plumbi subacetatis, 300, 353 

tragacanthae, 300 
Glycerita, 36 
Glycerites, 36 
Glyceritum acidi tannici, 509 

amyli, 300 

boroglycerini, 300 

hydrastis, 311 

phenolis, 435 

vitelli, 300 
Glycerol, 298 
Glycerole of aloes, 90 
Glycerophosphate of calcium, 170 
Glyceryl nitrate, 396, 397 
Glycyrrhiza, 355 

glabra, 355 
Glycyrrhizae radix, 355 



INDEX OF DRUGS AND REMEDIAL MEASURES 



973 



Glycyrrhizinum ammoniatum, 355 
Goa powder, 218 

Goetsch test for hyperthyroidism, 506 
Gold, 300 

and sodium chloride, 300 
Golden seal, 310 
Gonolobus condurango, 246 
Goodell's pill of the three valerianates, 
529 

sumbul pill, 502 
Goulard's extract, 352 
Graduated medicine glasses, 44 
Granatum, 451 
Granulated ferrous sulphate, 343 

opium, 418 
Gray oil, 368, 378 

powder, 379 
Green soap, 485 
Griffith's mixture, 339 

pills, 339 
Grindelia, 301 

robusta, 301 
Gruel, digested, 653 
Guaiac, 301 

resin, 301 
Guaiaci resina, 301 
Guaiacol, 302 

carbonate, 303 
Guaiacolis carbonas, 303 
Guaiacum, 301 

officinale, 301 
Gum acacia, 65 

arabic, 65 



Habit, cocaine, 237 

effect of, on dosage, 50 

morphine, 412 

treatment of, 413 
Town's, 413 
Haematoxyli lignum, 304 
Hamamelidis cortex, 304 

folia, 304 
Hamamelis, 304 

virginiana, 304 
Heat, 590 

dry, 598 
Heavy magnesia, 358 
Helmitol, 305 
Hematoxylin, 304 
Hematoxylon, 304 

campechianum, 304 
Hemlock fruit, 246 

juice, 246 

leaves, 246 
Hemoplastia, 599 
Hemostatic serum, 599 
Henbane, 316 
Heroin, 305 

hydrochloride, 305 
Herxheimer's reaction, 138 
Hexamethylenamine (urotropin, uri- 
tone), 305 



Hexamethylen-tetramine anhydrometh- 

ylen-citrate, 305 
Hexamine, 305 
Histamine, 269 
Hoffmann's anodyne, 306 
Holocaine, 307 

hydrochloride, 307 
Homatropinse hydrobromidum, 308 
Homatropine, 308 

Home modification of Turkish bath, 593 
Honey, 308 

of borax, 157, 309 

clarified, 309 

of rose, 309, 466 

of squill, 492 
Hop poultice, 309 
Hope s camphor mixture, 309 
Hops, 309 
Horse-nettle, 490 
Hot-air apparatus, Frazier-Lentz, 597 

Newell's, 598 
Hot pack, 596 

mustard, 386, 597 

Springs, 623 
House mixture, 485 
Huanuco coca, 232 
Humulus, 309 

lupulus, 309 
Husband's magnesia, 359 
Huxham's tincture, 229, 483 
Hychlorite, 543 
Hydragogue cathartics, 58 
Hydrargyri chloridum corrosivum, 372 
mite, 375 

iodidum navum, 381 
rubrum, 375 

oxidum navum, 380 
rubrum, 380 

per chloridum, 372 

salicylas, 381 

subchloridum, 375 

subsulphas flavus, 382 
Hydrargyrum, 363 

ammoniatum, 371 

cum creta, 379 

oleatum, 380 
Hydras tin a, 311 
Hydrastine, 310, 311 
Hydrastininae hydrochloridum, 311 
Hydrastinine hydrochloride, 311 
Hydrastis, 310 

canadensis, 310 

rhizoma, 310 
Hydrate of lime, 174, 176 
Hydrated chloral, 192 
Hydriodic acid, 311 
Hydriodide of scopolamine, 480 
Hydrobromic acid, 163 
Hydrobromide of coniine, 247 

of homatropine, 308 

of hyoscyamine, 317 

of pelletierine, 452 

of quinine, 226 

of scopolamine, 317, 480 
Hydrochloric acid, 311 



974 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Hydrochloride of apomorphine, 114, 116 

of cocaine, 232, 234, 237 

of cotarnine, 251 

of diacetylmorphine, 305 

of emetine, 333, 336 

of ethylhydrocuprein, 287 

of ethyl morphine, 267 

of eucaine, 287 

of heroin, 305 

of holocaine, 307 

of hydrastinine, 311 

of morphine, 420 

of para-amino - benzoyl-d i e t h y 1 - 
amino-ethanol hydrochloride, 458 

of pelletierine, 452 

of pilocarpine, 446 

of quinine, 226 
acid, 226 

of scopolamine, 480 

of strychnine, 407 
Hydrocyanic acid, 312 
Hydrogen peroxide, 314 

as an antiseptic, 547 
Hydro-iodide of scopolamine, 480 
Hydroxide of bismuth, 154 

of iron, 340 

with magnesium oxide, 340 

of potassium, 457 

of sodium, 488 
Hyoscinse hydrobromidum, 317 
Hyoscine, 317, 480 
Hyoscyami folia, 316 
Hyoscyaminse hydrobromidum, 317 
Hyoscyamine, 316 

hydrobromide, 317 

sulphate, 3 17 
* Hyoscyamus, 316 

leaves, 316 

nigra, 316 
Hyperemic treatment, Bier's, 556 
Hypnotics, 54, 57 
Hypodermic injection, 31 

of apomorphine, 116 
of cocaine, 237 
of ergot, 271 
of morphine, 421 

medication, 31 
Hypodermoclysis, 599 

apparatus for, and method of per- 
forming, 600 
Hypophosphite of calcium, 171, 172 
Hypophysis sicca, 448 
Hyposulphite of sodium, 490 



Ice-bag, 561 
Ice-coil, 563 
Ice-rub, 570 
Ichthyol, 318 
Idiosyncrasy, 44, 49 
Imperial drink, 454 

measure, 38 
Incompatibility, 58 



Indian hemp, 180 

poke, 530 
Indications for drugs, 50 
Indirect action of drugs, 30 
Infiltration anesthesia, 235, 236 

method of producing, 235, 236 
Infusion of eupatorium, 289 

of hops, 309 

of juniper, 345 

of matricaria, 363 

of pareira, 426 

of valerian, 529 

of wild cherry, 46 1 
Infusions, 36 
Infusum buchu, 166 

calumbse, 173 

caryophylli, 232 

cinchonse, 229 
acidum, 229 

digitalis, 264 

ergotae, 271 

gentianse compositum, 297 

quassise, 462 

rhei, 465 

rosse acidum, 466 

scoparii, 480 

senegse, 482 

sennse, 483 

compositum, 363, 483 

serpent arise, 483 

uvse ursi, 528 
Inhalations, 34, 601 

exercises to be used in, 602, 603, 
604 
Inhaler, Allis ether, 279 

chamber, 606 

Denison's resistance, 605 

Esmarch's chloroform, 210 

ethyl chloride, 286 

Evan's pocket, 609 

Lawrie's chloroform, 211 

menthol, 428, 609 

Yeo's creosote, 252, 609 
Injectio apomorphinse hypodermica, 116 

cocainas hypodermica, 237 

ergotse hypodermica, 271 

morphinse hypodermica, 421 
Injection, hypodermic, 31 

intra-abdominal, 33, 610 

intramuscular, 33 

intravenous, 33, 611 
technic of, 613 

longitudinal sinus, 33 

rectal, 33 
Inspissated ox-gall, 422 
Insufflation anesthesia, 281 
Intra-abdominal injection, 33, 610 
Intramuscular injection, 31, 33 
Intratracheal insufflation ether anesthe- 
sia, 281 
Intravenous injection, 31, 33, 611 
Inunctions, 35 
Iodalbin, 320 
Iodide of ammonium, 99 

of arsenic, 125 



INDEX OF DRUGS AND REMEDIAL MEASURES 



975 



333 



Iodide of iron, 341 

of lead, 352 

mercuric, red, 375 

mercurous, yellow, 381 

of potassium, 320 

of sodium, 324, 489 

of strontium, 324, 495 

of thymol, 515 
Iodine, 324 

as an antiseptic, 539 

contraindications to, 330 

ointment, 330 

poisoning by, 325 
Iodism, 323, 325 
Iodoform, 330 

as an antiseptic, 540 

ointment, 332 

poisoning by, 330 
Iodoformum, 330 
Iodol, 332 

collodion, 332 
Iodolum, 332 
Iodum, 324 
Ipecac, 333 
Ipecacuanha, 333 
Ipecacuanhae radix, 
Ipomoea purga, 343 
Iron, 336 

and ammonium sulphate, 337, 338 

aromatic mixture of, 338 

arsenate of, 338 

by hydrogen, 337, 341 

cacodylate of, 339 

carbonate of, 339 

chloride of, 337, 339 

citrates of, 340 

compound mixture of, 339 

hydroxide with magnesium oxide, 
128, 340 

iodide of, 341 

lactate of, 341 

phosphates of, 341 

plaster, 343 

Quevenne's, 337 

reduced, 337, 341 

subsulphate of, 337, 342 

sulphate of, 337, 343 

wines of, 343 
Isopilocarpine, 442 



Jaborixe, 442 
Jalap, 343 
Jalapa, 343 
Jalapin, 343, 478 
James' powder, 106 
Jamestown weed, 494 
Jasmine, yellow, 295 
Jateorrhiza palmata, 173 
Jequirity, 344 
Jervine, 530 

Joint effects of drugs, 47 
Juniper, 345 



Juniperin, 345 

Juniperus, 345 

communis, 345 
sabina, 477 

Junket, 658 



Kaolin, 345 

cataplasm of, 345 
Kaolinum, 345 
Kataphoresis, 35 
Kermes mineral, 103 
Kinic acid, 220 
Kino, 345 

Kinotannic acid, 345 
Kinovic acid, 220 
Klapp's suction cup, 558 
Kombe arrow-poison, 496 
Koumyss, 653 
Kreolin, 251, 546 

Krohne and Seseman's modification of 
Lawrie's chloroform inhaler, 212 



Labarraque's solution as disinfectant, 

541 
Laborde's rhythmic traction of tongue 

in accident by ether, 278 
Lactate of calcium, 170, 171 

of beta-eucaine, 288 

of eucaine, 288 

of iron, 341 

of strontium, 495 * 

Lactic acid bacillus, 346 
Lactone tablets, 650 

method of employing, 650 
Lactophenin, 72 
Lactophosphate of calcium, 172 
Lactose, 498 
Lamellae atropine, 149 

cocainse, 237 

homatropinae, 308 

physostigminse, 441 
Lanolin, 347 
Lard, benzoated, 151 
Laudanum, 418 
Laudinine, 409 
Laughing gas, 399 
Lavage, 616 

methods of performing, 616 
Lavements, 33 

Lawrie's chloroform inhaler, 211 
Laxatives, 58 
Lead, 348 

acetate, 351 

carbonate, 352 

iodide, 352 

oxide, 353 

plaster, 353 

sugar of, 351 

white, 352 



976 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Lead-water and laudanum, 352 
Lecithin, 353 
Leeches, 618 

application of, 620 

table of areas of, 619 
Leeching, 618 

therapeutics of, 619 
Lemon-juice, 231 

Lenhartz treatment of gastric ulcer, 7£ 
Leptandra, 354 
Leptandrin, 354 
Leptandrine, 354 
Levant wormseed, 476 
Levulose, 354 
Light magnesia, 358 
Lignum vitae, 301 
Lime, 173 

chlorinated, 174 

liniment, 174 

milk of, 174 

slaked, 174, 176 

sulphurated, 176 
Lime-water, 174 
Limitations of therapeutics, 29 
Lindeman method of transfusion, 635 
Lingual traction, 277 
Lini farina, 291 

semina, 290 
Liniments, 37 
Linimentum aconiti, 76 

ammoniae, 95 

belladonnas, 149 

calcis, 194, 291 

camphorae, 178 

ammoniatum, 179 

chloroforfni, 218 

crotonis, 255 

hydrargyri, 380 

saponis, 179, 485 
mollis, 485 

sinapis, 388 

compositum, 388 

terebinthinae, 528 
aceticum, 528 
Linseed, 290 

oil, 290 

poultice, 291 
Linum, 290 

usitatissimum, 290 
Lipo-vaccines, 643 
Liquefied phenol, 435 
Liquid petrolatum, 430 
Liquor acidi arsenosi, 124, 125 
chromici, 218 

adrenalinum hydrochloricus, 506 

alumini acetatis, 91 

ammoniae, 95 
fortis, 95 

ammonii acetatis, 96 
citratis, 100 

arseni et hydrargyri iodidi, 125 

arsenicalis, 124 

arsenici hydrochloricus, 125 

atropinae sulphatis, 149 

bismuth et ammonii citratis, 152 



Liquor calcis, 174 

chlorinatae, 176 

saccharatus, 176 
calumbae concentratus, 173 
carbonis detergens, 767 
cresolis compositus, 358 
epispasticus, 184 
ferri acetatis, 343 

chloridi, 340 

citratis, 340 

et ammonii acetatis, 337, 338 

perchloridi, 340 
fortis, 340 

persulphatis, 342 

subsulphatis, 342 

tersulphatis, 128 
formaldehydi, 292 
hamamelidis, 305 
hydrargyri nitratis acidus, 380 

perchloridi, 374 
hydrogenii dioxidi, 314 

peroxidi, 314 
hypophysis, 448 
iodi compositus, 329 
magnesii bicarbonatis, 359 

citratis, 359 
morphinae acetas, 421 

hydrochloridi, 421 

sulphatis, 420 

tartratis, 421 
pancreatitis, 425 
pepsini, 429 

plumbi subacetatis, 352 
dilutus, 353 
fortis, 352 
potassae, 355 
potassii arsenitis, 124 

citratis, 453, 456 

hydroxidi, 355 

permanganatis, 430 
sarsae compositus concentratus, 477 
sennae concentratus, 483 
sodae chlorinatae as an antiseptic, 

541 
sodii arsenatis, 124 

ethylatis, 489 

hydroxidi, 489 

physiologicus, 488 
strychninae hydrochloridi, 407 
thyroidei, 519 
trinitrini, 396, 397 
zinci chloridi, 534 
Liquorice, 355 
root, 355 
Liquors, 37 
Litharge, 353 
Lithia-water, 356, 622 
Lithii bromidum, 163, 356 
carbonas, 356 
citras, 356 
salicylas, 356 
Lithium, 356 

bromide, 163, 356 
Liver, 298 ' 
Lobelia, 356 



INDEX OF DRUGS AXD REMEDIAL MEASURES 



977 



Lobelia, inflata, 356 

Lobelic acid, 356 

Lobeline, 356 

Loeffler's solution, 751 

Loewi test for pancreatic insufficiency, 

506 
Lofoten cod-liver oil, 239 
Logwood, 304 
Lotio hydrargyri flava, 382 

nigra, 375 
Lozenges, 37 
Lugol's solution, 329 
Lumbar puncture, 620 
Luminal, 357 

sodium, 357 
Lunar caustic, 390 
Lung expansion, arrangement of bottles 

for promoting, 605 
Lupulin, 309 
Lupuline, 309 
Lupulinic acid, 309 
Lupulinum, 309 
Lupulus, 309 
Lycetol, 448 
Lycopodium, 358 

clavatum, 358 
Lysol, 358 



M 



Magendie's solution, 420 
Magma bismuthi, 154 

magnesise, 360 
Magnesia, 359 

calcined, 359 

levis, 359 

ponderosa, 359 
Magnesii carbonas, 358 
levis, 358 
ponderosus, 358 

citras, 359 

effervescens, 359 

oxidum, 359 

ponderosum, 359 

sulphas, 360 

effervescens, 361 
Magnesium, 358 
Male fern, 140 
Malt, milk, flour and, 659 

soup, 659 
Mandrake, 451 
[Manganese, 362 

sulphate, 362 
Mangani dioxidum praecipitatum, 362 
Manganum, 362 
Manna, 362 
Marsden paste, 124 
Massa copaibse, 248 

ferri carbonatis, 339 

hydrargvri, 375 
Matricaria, 363 

chamomilla, 363 

infusion of, 363 
May apple, 451 
62 



Meadow saffron, 242 

Measures, weights and, 37 

Meconic acid, 409 

Meconine, 409 

Medication by cataphoresis, 31, 35 

endermic method, 35 

fumigation, 31 

hvpodermic injection, 31 

inhalation, 31, 34 

intramuscular injection, 31, 33 

intravenous, 31, 33 

inunction, 31, 35 

mouth, 31 

rectum, 31, 33 

sublingual, 31 
Medicine glasses, graduated, 44 
Medinal, 142, 143 
Mel, 308 

boracis, 157, 309 

depuratum, 309 

rosse, 309, 466 
Melaleuca leucodendron, 169 
Melia azedarach, 141 
Mentha piperita, 426 
Menthol, 427 

inhaler, 428, 609 
"Mercurettes," 379 
Mercurial fumigator, 366 

ointment, 379 
diluted, 379 

pills, 375 

plaster, 380 
Mercurialized serum, 373 
Mercuric nitrate, 380 

oxides, 380 
Mercurol, 363 
Mercury, 363 

ammoniated, 371 

as an antiseptic, 538 

bichloride, 372 , 

biniodide, 375 

ointment, 379 

oleate of, 379 

protoiodide, 381 

salicylate, 381 

with chalk, 379 
Metadioxybenzol, 462 
Metagen, 532 
Methvl blue, 383 

chloride, 384 

salicylas, 295 

violet, 383 
Methylene blue (methvlthionine chlo- 
ride), 384 

chloride, 385 
Methylene-citryl-salicylic acid, 403 
Methylis salicylas, 295 
Methylsulphonal, 520 
Methylthionine chloride (methylene 

blue), 384 
Metric equivalents, 39, 40 

svstem of weights and measures, 
38, 39 
Mild mercurous chloride, 375 
Milk, almond, 658 



978 



INDEX OF DRUGS AND REMEDIAL MEASURES 



651 



56 



Milk, artificial, 658 

of asafcetida, 139 

of bismuth, 154 

butter-, and starch, 649 

casein, 649 

flour and malt, 659 

of lime, 174 

of magnesia, 359 

peptonized, 650 

of sulphur, 500 

whole, feeding for infants, 651 
Milk-punch, 85 _ 

peptonized 
Milk-sugar, 498 
Mineral astringents, 

cathartics, 58 

springs, 622 
Mint camphor, 427 

stearopten, 427 
Mistura ammoniaci, 95 

amygdalae, 88 

chloroformi et cannabis composita, 
198 

creosoti, 254 

cretse, 170 

ferri aromatica, 338 
composita, 339 

glycyrrhizse composita, 355 

guaiaci, 301 

olei ricini, 191 

potassii citratis, 456 

sennse composita, 483 

spiritus vini gallici, 87 
Mitigated caustic, 393 
Mixed phylacogens, 628 
Mixtures, 37 
Modes of action of drugs, 20, 30 

of administering drugs, 31 
Monkshood, 72 
Monobromated camphor, 179 
Monochlorethane, 284 
Monochlormethane, 384 
Monohydro chloride of benzoyl, 92 
Mcnosodium phosphate, 487 
Monsel's salt, 337, 342 

solution, 342 
Moro tuberculin test, 525 
Morphina, 420 
Morphinse hydro chloridum, 420 

sulphas, 420 

tartras, 402 
Morphine, 409, 420 

habit, 412 

treatment of, 413 

Town's method of, 413 
Morrhuol, 239 
Moschus, 386 

moschiferus, 386 
Mouth, administration of drugs by, 31 
Mucilage of acacia, 65 
Mucilago acacise, 65 
Mulled wine, 85, 659 
Muriate of ammonium, 98 

of morphine, 420 
Murphy drip, 888 



Musk, 386 
Mustard, 386 

hot pack, 387, 597 

papers, 387 

plaster, 387, 581 
Mydriatics, 54 
Myotics, 54 
Myristica, 403 

fragrans, 403 
Myrrh, 388 
Myrrha, 388 
Myrrhin, 388 

N 

Naphthol, 151 
Narceine, 409 
Narcotine, 409 
Nebulizer, glaseptic, 610 

Oliver's, 610 
Nebulizers, 35, 610 
Neoarsphenamine, 130, 388 
Neocinchophen, 390 
Neosalvarsan, 130, 388 
Nervous sedatives, 54, 57 

stimulants, 54, 58 
Neutral mixture, 456 
Newell's hot-air apparatus, 598 
Newman's proctoclysis apparatus, 890 
Nitrate of mercury, 380 

of pilocarpine, 446 

of potassium, 457 

of silver, 390 

of strychnine, 407 
Nitre, 457 
Nitric acid, 393 
Nitrite of amyl, 100 

of potassium, 395 

of sodium, 395 
Nitrogen monoxide, 399 
Nitrogenii monoxidum, 399 
Nitroglycerin, 396 
Nitrohydrochloric acid, 312, 397 
Nitrous oxide, 399 

and oxygen anesthesia, 400 

oxide-oxygen-ether apparatus, 401 
Normal saline solution, 487, 611 
Norwood's tincture of veratrum, 531 
Novaspirin, 403 
Novatophan, 390 
Novocaine, 458 
Nut-gall, 294, 508 
Nutmeg, 403 
Nutrient enema, 33, 652 
Nux vomica, 404 



Oatmeal- water, 656 
Oil of amber, 92 

Carron, 291 

of erigeron, 272 

of garlic, 87 

of gaultheria, 295 






INDEX OF DRUGS AND REMEDIAL MEASURES 



979 



Oil, phosphorated, -439 


Oleum amygdalae expressum, 88 


of rue, 466 


cajuputi, 169 


of savine, 477, 478 


caryophylli, 231 


of tar, 510 


chenopodii, 191 


of vitrol, 501 


cinereum, 368, 378 


Ointment of aconitine, 76 


cinnamomi, 230 


of ainmoniated mercury, 371 


copaibae, 248 


of antimony, 106 


crotonis, 254 


of atropine, 149 


cubebae, 255 


of belladonna, 149 


eucalypti, 288, 289 


of boric acid, 156 


jecoris aselli, 239 


of calomel, 378 


juniperi, 345 


of cantharides, 184 


lini, 290 


. of capsicum, 186 


menthae piperitae, 427 


of carbolic acid, 435 


morrhuae, 239 


of chrysarobin, 218 


myristicae, 403 


of cocaine, 237 


phosphoratum, 439 


of conium, 247 


picis liquidae, 510 


of creosote, 254 


pimentae, 447 


of eucalyptus, 289 


ricini, 188 


of gallic" acid, 293 


santali, 475 


of galls, 294 


sinapis volatile, 386 


with opium, 294 


succini, 92 


of hamamelis, 305 


tanaceti, 509 


of iodide of lead, 352 


terebinthinae, 526 


of iodine, 330 


rectificatum, 526 


of iodoform, 332 


tiglii, 254 


of lead acetate, 352 


Valerianae, 529 


carbonate, 352 


Ophthalmo-tuberculin test, 525 


iodide, 352 


Opii pulvis, 418 


subacetate, 353 


Opium, 409 


of mercurv, 379 


deodoratum, 418 


diluted, 379 


granulatum, 418 


of nitrate of mercury, 380 


poisoning, acute, differentiation of, 


of oleate of mercury, 380 


from acute alcoholism, 82 


of oxide of zinc, 534 


Opodeldoc, 485 


of phenol, 435 


Opsonotherapy', 639 


of red iodide of mercury. 375 


Optochin, 287" 


oxide of mercury, 381 


Orphol, 152 


of resin, 462 


Orthoform, 421 


of rose-water, 466 


"new," 421 


of salicylic acid, 473 


Ouabain, 496 


of stramonium, 494 


Ourouparia gambier, 294 


of sulphur, 500 


Ovarian extract, 298, 421 


of tannic acid, 509 


Oxalate of cerium, 191 


of tar, 510 


Ox-gall, 422 


of tartrate of antimony, 106 


Oxide of antimony, 103 


of turpentine, 527 


of calcium, 173 


of veratrine, 530 


of lead, 353 


of yellow oxide of mercury, 381 


of magnesium, 359 


Ointments, 37 


heavy* 359 


Old tuberculin, 521 


of mercury, 380 


Oleate of aconitine, 75 


nitrous, 399 


of cocaine, 234 


of zinc, 534 


of mercury, 379, 380 


Oxvgen, 422 


Oleatum hydrargyri, 379, 380 


Oxvmel, 308 


Oleoresin of copaiba, 248 


scillae, 492 


Oleoresina aspidii, 140 


Oxytocics, 54, 58 


capsici, 186 


Oysters, peptonized, 651 


cubebae, 255 




petroselini, 114 




piperis, 426 


P 


zingiberis, 297 




Oleum amygdalae, 88 


Pack, hot, 596 


amarae, 88 


mustard, 597 



980 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Pancreas, 298 

Pancreatin, 424 

Pancreatinum, 424 

Panopsum hydrochloridum, 419 

Pantopon, 419 

Papain, 425 

Papaver somniferum, 409 

Papaverine, 409 

Papayotin, 425 

Papers, 36 

Papoid, 425 

Para-amino-benzoyl-diethylamino- 

ethanol hydrochloride, 458 
Paraldehyde, 425 
Paraldehydum, 425 
Parathyroid gland, 426 
Paregoric, 418 
Pareira, 426 
Pareire radix, 426 
Parsley, 113 
Pearson's solution, 125 
Pellet ierine tannas, 452 
Pelletierine, 452 

hydrobromide, 452 

hydrochloride, 452 

sulphate, 452 

tannate, 452 
Pepo, 426 
Pepper, 426 

cayenne, 184 
Peppermint, 426 
Peppermint-water, 427 
Pepsin, 429 

cordial, 429 
Pepsinum, 429 
Peptonized beef, 651 
enemata, 652 

milk, 650 

punch, 651 

oysters, 651 
Percentages, table of approximate, 41 
Permanganate of potassium, 429 
Peroxide of hydrogen, 314, 547 
Persulphate of iron, 343 
Petrolatum, 430 

album, 430 

liquidum, 430 
Petroselinum, 113 
Pharmaceutical preparations, 36 
Phenacetin (acetphenetidin) , 71 
Phenacetinum (acetphenetidinum) , 71 
Phenazone, 108 
Phenazonum, 108 
Phenic acid, 431 
Phenol, 431 

as an antiseptic, 539 

glycerite of, 435 

liquefied, 435 

ointment of, 435 
Phenolbarbital, 357 

sodium, 357 
Phenolphthalein, 435 
Phenolsulphonate (sulphocarbolate) of 
sodium, 435 

of zinc, 435, 547 



Phenyl-acetamide, 66 
< Phynylcinchonic, 141 
Phynyl-dimethyl-pyrazolon, 108 
Phenyl-ethyl-barbituric acid, 357 
Phenylic alcohol, 431 
Phenylis salicylas (salol), 473 
Phlebotomy, 644 
Phosphate of ammonium, 100 

of calcium, 170 

of codeine, 238 

of iron, 341 

of sodium, 488 

of strontium, 495 
Phosphorated oil, 439 
Phosphoric acid, 436 
Phosphorus, 436 
Phylacogens, 628 
Physostigma, 439 

venenosum, 439 
Physostigmatis semina, 439 
Physostigmine salicylas, 441 
Physostigmine, 440 
Picea, 448 

Picrasma excelsa, 461 
Picric acid, 441 
Pill of three valerianates, 529 
Pills, 37 
Pilocarpine hydrochloridum, 446 

nitras, 446 
Pilocarpine, 442 
Pilocarpus, 442 

jaborandi, 442 

microphyllus, 442 
Pilula aloes et asafcetide, 90 
et ferri, 90 
et myrrhe, 90 

colocynthidis composita, 245 
et hyoscyami, 245 

galbani composita, 140 

hydrargyri, 375 

subchloridi composita, 378 

ipecacuanhas cum scilla, 336 

plumbi cum opio, 352 

quinine sulphatis, 227 

saponis composita, 419 

scammonii composita, 478 
Pilule aloes, 90 

et myrrhe, 388 

antimonii composite, 106 

asafcetide, 139 

cathartice composite, 245 
vegetables, 245 

ferri, 339 

carbonatis, 339 
iodidi, 341 

phosphori, 439 

rhei, 464 

composita, 464 
composite, 464 

scille composita, 492 
Pimenta, 447 

officinalis, 447 
Pinkroot, 491 
Pinus palustris, 509 

sylvestris, 509 



INDEX OF DRUGS AND REMEDIAL MEASURES 



981 



Piper, 426 

cubeba, 255 

nigrum, 426 
Piperazina, 447 
Piperazine, 447 
Piperine, 426 
Pitch, 448 
Pituitary gland, 448 
Pituitrin, 448 
Pix, 448 

burgundica, 448 

canadensis, 448 

liquida, 509 
Plaster of arnica, 1 17 

of asafcetida, 139 

of belladonna, 149 

of Canada pitch, 448 

of cantharides, 184 

of capsicum, 186 

of iodide of lead, 352 

of iron, 343 

of lead, 353 

of menthol, 429 

of mercury, 380 

mustard, 387, 581 

of pitch, 448 

of soap, 486 

spice, 581 

warming, 184, 448 
Plasters, 36 
Plumbi acetas, 351 

carbonas, 352 

iodidum, 352 

oxidum, 353 
Plumbum, 348 
Plummer's pills, 106 
Podophylli resina, 451 
Podophyllin, 451 
Podophyllum, 451 

peltatum, 451 
Poke-root, 530 
Pollen proteins, 630 
Polvgala senega, 482 
Polygallic acid, 482 
Pomegranate, 451 
Port wine, 86 
Porter, 86 
Potash papers, 458 
Potassa caustica, 457 

cum calce, 174, 457, 532 
Potassii acetas, 453 

bicarbonas, 453 

bitartras, 453 

bromidum, 157 

carbonas, 454 

chloras, 454 

citras, 456 

effervescens, 456 

cyanidum, 457 

et sodii tartras, 465 

hydroxidum, 457 

iodidum, 320 

nitras, 457 

permanganas, 429 

tartras acidus, 453 



Potassium acetate, 453 

bicarbonate, 453 

bitartrate, 453 

bromide, 157 

carbonate, 454 

chlorate, 454 

citrate, 456 

cobalto-nitrite, 395 

cyanide, 457 

guaiacol-sulphonate, 513 

hydroxide, 457 

iodide, 320 

nitrate, 457 

nitrite, 395 

permanganate, 429 

silicate, 483 
Poultice of charcoal, 186 

of flaxseed, 291 

of kaolin, 345 

of starch, 493 
Poultices, 36 

Precipitated carbonate of calcium, 170 
of zinc, 534 

dioxide of manganese, 362 

phosphate of calcium, 170, 172 

sulphur, 500 
Preparations, pharmaceutical, 36 
Prepared chalk, 170 
Prescription, parts of a, 61 

writing, 60 
Pride of China, 141 
Procaine (novocaine), 458 
Proctoclysis, Newman's apparatus for, 

890 
Proflavins, 546 
Protargol, 460 
Proteins, pollen, 630 
Protoiodide of mercury 381 
Protoveratrine, 530 
Protoxide of nitrogen, 399 
"Provocative dose" of arsphenamine in 

syphilitics, 132 
Pruni virginianae cortex, 460 
Prunus virginiana, 460 
Prussic acid, 312 
Pseudomorphine, 409 
Psychotria ipecacuanhas, 333 
Psychotrine, 333 
Pterocarpus marsupium, 345 
Pulvis amygdalae compositus, 88 

antimonialis, 103, 106 

aromaticus, 188, 230 

catechu compositus, 294 

cinnamomi compositus, 230 

cretae aromaticus, 171 
compositus, 170 
cum opio, 171 

effervescens compositus, 481 

elaterini compositus, 269 

glycyrrhizae compositus, 355, 483 

ipecacuanhae compositus, 336, 419 
et opii, 336, 419 

jalapae compositus, 344 

kino compositus, 346 

morphinse compositus, 421 



982 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Pulvis opii compositus, 419 
rhei compositus, 464 
scammonii compositus, 478 
sodse tartratse effervescens, 481 

Pumpkin-seed, 426 

Punch, milk, 85 

peptonized, 651 

Punica granatum, 451 

Punk, 77 

Pure extract of glycyrrhiza, 355 

Purgative mineral waters, 623 

Purgatives, 58 

Purified chloroform, 199 
ox-gall, 422 
sulphide of antimony, 103 

Pyoktanin, 384 

Pyrogallic acid, 461 

Pyrogallol, 461 

Pyrophosphate of iron, 341 



Q 

Quassia, 461 

infusion of, 461 
Quassias lignum, 461 
Quassin, 461 
Queen's root, 493 
Quercus, 462 

infectoria, 294 

tinctoria, 462 
Quevenne's iron, 337, 341 
Quicksilver, 363 
Quinicine, 220 
Quinidina, 220 
Quinidinse sulphas, 229 
Quinidine, 220 

sulphate, 229 
Quinina, 220 
Quininae bisulphas, 226 

dihydrochloridum, 226 

et ureae hydrochloridum, 228 

hydrobromidum, 227 

hydrochloridum, 226 
acidum, 226 

salicylas, 227 

sulphas, 227 

tannas, 227 

valeras, 227, 529 
Quinine, 220 

acid hydrochloride of, 226 

and urea, bimuriate of, 228 

bisulphate, 226 

chocolates, 227 

ethylcarbonate, 290 

hydrobromide, 226 

hydrochloride, 226 

salicylate, 227 

sulphate, 227 

tannate, 227 

valerate, 227, 529 



Raspberry, 466 
Reaction, Herxheimer, 138 



Rectal drip, 888 

ether anesthesia, 282 

medication, 31, 33 
Rectified spirit, 87 
Red cinchona, 220 

mercuric iodide, 375 
oxide, 380 

precipitate, 380 
ointment, 381 

rose, 465 

wine, 86 
Reduced iron, 337, 341 
Reliability and strength of drugs, 48 
Remedial measures other than drugs, 

537 
Remedy, cold as a, 560 
Resin, 462 

cerate, 462 

compound, 462 

of guaiac, 301 

ointment, 462 
Resina, 462 

jalapse, 344 

podophylli, 451 

scammonii, 478 
Resistance inhaler, Denison's, 605 
Resorcinol, 462 
Resorcinum, 462 
Rest cure, 631 

in the treatment of disease, 20 
Restorative beef-essence, 656 
Revulsives, 54 
Rhamnus purshiana, 188 
Rhei radix, 464 
Rheum, 464 
Rhigolene, 464 
Rhubarb, 464 
Rhus aromatica, 465 

glabra, 465 
Rice-water, 656 

Richaud's table indicating areas of skin 
to which leeches or cups may be ap- 
plied, 619 
Ricinoleic acid, 189 
Ricinus communis, 188 
Roborants, 54 
Rochelle salt, 465 
Rodagen, 519 
Rosa gallica, 465 

gallicse petala, 465 
Rose-water, 466 
Rosin, 462 

Rubefacients, 56, 577, 581 
Rubus ideus, 466 
Rue, 466 

Rules for dosage, 44, 45 
Rum, 86 

Russian bath, 595 
Ruta graveolens, 466 



Sabina, 477 

Saccharated carbonate of iron, 337, 
339 



INDEX OF DRUGS AND REMEDIAL MEASURES 



983 



Saccharated iodide of iron, 341 

solution of lime, 176 
Saccharin (benzosulphanidum), 466 
Saccharum, 498 

lactis, 498 

officinarum, 498 

purification, 498 
Sal ethyl, 467 

prunella, 457 
Salicin, 467 
Salicinum, 467 
Salicylate of bismuth, 155 

of ethyl, 467 

of lithium, 356, 468 

of mercury, 380 

of methyl, 295, 467 

of phenyl (salol), 473 

of physostigmine, 441 

of quinine, 227 

of sodium, 467 

of strontium, 495 
Salicylic acid, 468 

ointment, 473 
' poisoning by, 469 
untoward effects of, 472 
Salol (phenyl salicylate), 473 
Salophen, 474 
Salophenum, 474 
Salt, 488 
Saltpetre, 457 
Salts, 360 
Salvarsan, 129 

contraindications to, 138 

natrium, 138 

untoward effects of, 137 
Salvarsanized serum, 133 
Sandalwood oil, 475 
Sanguinaria, 475 

canadensis, 475 
Sanguinarine, 475 
Santalum album, 475 
Santonica, 476 
Santonin, 476 

poisoning by, 476 
Santoninate of sodium, 476 
Santoninic acid, 476 
Santoninum, 476 
Sapo, 485 

durus, 485 

mollis, 485 
Sarsaparilla, 477 
Savine, 477 
Scammonia radix, 478 
Scammonise resinse, 478 
Scammony, 478 
Scarlet red, 478 
Schick test, 756 
Schleich's anesthetic fluid, 236 
Scilla, 491 
Scillin, 491 
Scillipicrin, 491 
Scillitoxin, 491 
Sclerotinic acid, 269 
Scopari cacumina, 479 
Scoparin, 479 



Scoparius, 479 

Scopola, 480 

Scopolamine hydrobromidum, 317, 480 

Scopolamine, 480 

hydriodide, 480 

hydrobromide, 317, 480 

hydrochloride, 480 
Scopolamine-morphine anesthesia, 480 
Sedatives, cardiac, 52, 56 

nervous, 54, 57 

vasomotor, 55, 58 
Seidlitz powder, 481 
Senega, 482 
Senegae radix, 482 
Senegin, 482 
Senna, 482 

Alexandrina, 482 

confection of, 482 

Indica, 482 
Sensitized vaccine, 643 
Serpentaria, 483 
Serpentariae rhizoma, 483 
Serum, antidiphtheritic, 549 

antidiphtheriticum purificatum, 
549 
siccum, 550 

antidysenteric, 551 

antigonococcic, 551 

antimeningitis, 552 

antipneumococcic, 553 

antipoliomyelitis, 554 

antistreptococcus, 554 

antitetanicum, 554 
purificatum, 555 
siccum, 555 

hemostatic, 599 

mercurialized, 373 

salvarsanized, 133 
Sherry, 87 

Sick, feeding the, 646 
Silicate of potassium, 483 

of sodium, 483 
Silver arsphenamine, 484 

nitrate, 390 
Silvol, 484 
Sinapis alba, 386 

nigra, 386 
Sinapisma, 388 
Slaked lime, 176 
Sleep in disease, 20 
Smilax, 477 

medica, 477 

ornata, 477 
Smooth sumach, 465 
Snake-root, black, 219 
Snake-weed, 289 
Soap, 485 

castile, 485 

green, 485 

liniment, 179, 485 

plaster, 486 
Soda caustica, 489 

tartrata, 465 
Sodii acetas, 487 

arsenas, 117, 125 



984 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Sodii arsenas exsiccatus, 125 

bicarbonas, 487 

boras, 156 

bromidum, 163 

cacodylas, 487 

chloridum, 488 

citras, 488 

et potassii tartras, 465 

hydroxidum, 489 

hyposulphis (thiosulphas), 490 

iodidum, 324, 489 

nitris, 395 

phenolsulphonas, 435 

phosphas, 489 
acidus, 487 
effervescens, 489 
exsiccatus, 489 

salicylas, 467 

santoninas, 476 

sulphas, 490 

effervescens, 490 

sulphocarbolas, 435 

thiosulphas (hyposulphis), 490 
Sodio-benzoate, caffeine, 167 
Sodio-theobromine-salicylate, 486 
Sodium, 487 

acetate, 487 

acid phosphate, 487 

arsenate, 117, 125 
exsiccated, 125 

arsphenamine, 139 

bicarbonate, 487 

borate, 156 

bromide, 163 

cacodylate, 487 

chloride, 488 

citrate, 488 

ethylate, 488 

hydroxide, 489 

hyposulphite (thiosulphate), 490 

ichthyol, 318 

iodide, 324, 489 

nitrite, 395 

phenolsulphonate, 435 

phosphate, 489 
acid, 487 
effervescing, 490 
exsiccated, 490 

salicylate, 473 

salvarsan, 138 

santoninate, 476 

silicate, 483 

sulphate, 490 

sulphocarbolate, 435, 490 

thiosulphate (hyposulphite), 490 
Soft petrolatum, 430 

soap, 485 
Solanum Carolinense, 491 
Soluble citrate of iron and quinine, 340 

glass, 483 

phosphate of iron, 341 
Solution of acetate of ammonium, 96 
of iron, 338, 343 
of morphine, 421 

alum acetate, 91 



Solution of ammonia, 95 

of arsenate of sodium, 124 
of arsenite of potassium, 124 
of arsenous acid, 125 

and mercuric iodide, 125 
of bicarbonate of magnesium, 359 
of chloride of adrenalin, 506 
of iron, 340 
of zinc, 534 
of chlorinated lime, 176 
of chromic acid, 218 
of citrate of ammonium, 100 

of bismuth and ammonium, 

152 
of iron, 340 
of magnesium, 359 
of potassium, 453, 456 
Dobell's, 155 
of formaldehyde, 292 
of hydrochloride of morphine, 421 

of strychnine, 407 
of hydrogen dioxide, 314 
of iodide of arsenic and mercurv, 

125 
of iodine, 329 
of iron and ammonium acetate, 337, 

338 
of lime, 174 
Magendie's, 420 
Monsel's, 342 
of nitrate of mercury, 380 
normal saline, 487, 611 
of pancreas, 425 
of pepsin, 429 
of perchloride of iron, 340 

of mercury, 374 
of permanganate of potassium, 430 
of potassa, 355 
of potassium citrate, 453, 456 

hydroxide, 355 
of sodium ethylate, 488 

hydroxide, 488 
of subacetate of lead, 352 
of sulphate of atropine, 149 
of iron, 342 
of morphine, 421 
of tartrate of morphine, 421 
of tersulphate of iron, 128 
Sorghum, 497 
Soup, malt, 659 

Soya bean flour for infant feeding, 655 
Spanish fly, 182 
Sparteine sulphas, 479 
Sparteine, 479 
Spice plaster, 581 
Spigelia, 491 

marilandica, 491 
Spinal anesthesia, method of inducing, 
458 
mode of introducing the needle 
in, 459 
extracts, 298 
Spirit of Mindererus, 96 
of nitrous ether, 506 
of turpentine, 526 



INDEX OF DRUGS AND REMEDIAL MEASURES 



985 



Spirits, 37 

Spiritus setheris, 283 

compositus, 306 
nitrosi, 506 

ammonise aromaticus, 95 
fcetidus, 95 

cajuputi, 169 

camphorse, 178 

chloroformi, 213, 218 

cinnamomi, 230 

frumenti, 86 

glycerylis nitratis, 396, 397 

juniperi, 345 

compositus, 86, 345 

menthse piperita?, 427 

myristicse, 403 

odoratus, 86 

phosphori, 439 

rectificatus, 87 

vini gallici, 86 
Sponging, cool, 567 
Sprays, atomized, 35 
Springs, hot, 623 

mineral, 622 
Squill, 491 

Squirting cucumber, 268 
Starch, 493 

buttermilk and, 649 

glycerite of, 300 

poultice, 493 
Starch-water, 493 
Steam vaporizer, 35, 607 
Steapsin, 424 
StiUingia, 493 

sylvatica, 493 
Stillingin, 493 
Stimulants, cardiac, 52, 56 

nervous, 54, 58 

vasomotor, 55, 58 
Stomach-pump, 617 
Stout, 86 
Stovaine, 494 
Stramonii folia, 494 
Stramonium, 494 
Strength, relative, of drugs, 48 
Stretcher, bath, 571 
Stronger water of ammonia, 95 
Strontii bromidum, 495 

iodidum, 324, 495 

salicylas, 495 
Strontium, 495 

bromide, 495 
iodide, 324, 495 

lactate, 495 
phosphate, 495 
salicylate, 495 
Strophanthi semina, 496 
Strophanthidin, 496 
Strophanthin, 496 
Strophanthinum, 496, 497 
Strophanthone, 497 
Strophanthus, 496 
gratus, 496 
hispidus, 496 
kombe, 496 



Strychninse nitras, 407 

sulphas, 407 
Strychnine, 404 

hydrochloride, 407 

nitrate, 407 

sulphate, 407 
Strychnos nux vomica, 404 
Styptic collodion, 244, 509 
Stypticin, 251 
Styrax benzoin, 150 
Subcarbonate of bismuth, 153 
Subgallate of bismuth, 152 
Sublimed sulphur, 500 
Sublingual medication, 31 
Subnitrate of bismuth, 153 
Subsalicylate of bismuth, 155 
Subsulphate of iron, 337, 342 
Succinum, 92 
Succus belladonnse, 149 

conii, 247 

limonis, 231 

scoparii, 480 

taraxaci, 511 
Sugar, 498 

beet-, 498 

of lead, 351 

of milk, 498 
Sugar-cane, 498 
Sulphate of aluminum and potassium, 90 

of ammonium, 100 

of atropine, 143, 149 

of calcium, 170, 173 

of cinchonidine, 229 

of cinchonine, 229 

of codeine, 238 

of copper, 248 

of duboisine, 267 

of hyoscyamine, 317 

of iron, 337, 343 

and ammonium, 337, 338 

of magnesium, 360 

of manganese, 362 

of morphine, 420 

of pelletierine, 452 

of physostigmine, 441 

of quinidine, 229 

of quinine, 227 

of sodium, 490 

of sparteine, 479 

of strychnine, 407 

of zinc, 536 
Sulphide of antimony, 103 
Sulphocarbolate (phenolsulphonate) of 
sodium, 435 
of zinc, 435 
Sulphonal (sulphomethane), 498 
Sulphonalum, 498 

Sulphonethylmethanum (trional), 520 
Sulphonmethanum (sulphonal), 498 
Sulphur, 500 
lotum, 500 
milk of, 500 
ointment, 500 
praecipitatum, 500 
springs, 624 



986 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Sulphur sublimatum, 500 
Sulphurated antimony, 103 

lime, 176 
Sulphuric acid, 501 

lemonade, 502 

ether, 272 
Sumach, smooth, 465 

sweet, 465 
Sumbul, 502 

pill, Goodell's, 502 

radix, 502 
Suppositoria acidi tannici, 509 

belladonnas, 149 

glycerini, 299 

iodoformi, 332 

morphinas, 421 

plumbi composita, 352 
Suppositories, 34, 37 

of asafcetida, 139 
Suppositorium acidi carbolici, 435 
Suprarenal gland, 503 
Suprarenalum siccum, 503, 506 
Swamp hellebore, 530 
Sweet almonds, 87 

spirit of nitre, 506 

sumach, 465 
Sydenham's laudanum, 419 
Symptoms, relief of, in disease, 20 
Syrups, 37 
Syrupus acacias, 65 

acidi citrici, 231 
hydriodici, 311 

allii, 87 

calcii lactophosphatis, 172 

cascaras aromaticus, 188 

chloral, 196 

codeinse phosphatis, 239 

ferri iodidi, 341 

phosphatis, 341 

cum quinina et strychnin a, 
341 
quininas et strychninae phos- 
phatum, 341 

hypophosphitum, 172 
cum ferro, 341 

ipecacuanhas, 336 

limonis, 231 

picis liquidas, 510 

pruni virginianae, 461 

rhei, 465 

aromaticus, 465 

rosas, 466 

rubi idasi, 466 

sarsaparillas compositus, 477 

scillae, 492 

compositus, 106, 492 

senegas, 482 

sennas, 483 

zingiberis, 297 



Tabeli^e trinitrini, 398 

Table of approximate percentages, 41 



Table, comparative, showing strengths 
of substances and preparations in 
preceding and present pharma- 
copoeia, 9 

Richaud's, indicating areas of skin 
to which leeches or cups may be 
applied, 619 
Tables of relative weights and measures 
in the metric and apothecaries' sys- 
tems, 40 
Tablet triturates, 37 
Tablets, 37 

of nitroglycerin, 397 
Taka-diastase, 256 
Tamarinds, 508 
Tamarindus, 508 
Tanacetum, 509 

vulgare, 509 
Tannate of pelletierine, 452 

of quinine, 227 
Tannic acid, 508 
Tansy, 509 

tea, 509 
Tar, 509 

oil of, 509 

ointment, 510 

wine of, 510 
Taraxacum, 510 
I Tartar emetic, 103, 106 
! Tartaric acid, 511 

i Tartrate of antimony and potassium, 
103 

of morphine, 420 

of potassium and sodium, 465 
Tar-water, 510 
Tea, beef-, 655 

flaxseed-, 291 
Temperament, effect of, on dosage, 50 
Terebene, 511 
Terebenum, 511 
Terebinthina, 526 
Terpine hydrate, 511 
Terpini hydras, 511 
Terpinol, 512 
Test, Goetsch, 506 

Loewi, 506 

Schick, 756 

tuberculin, Moro, 525 
ophthalmo, 525 
von Pirquet's, 525 
Testicular juice, 298 
Thapsia, 512 

garganica, 512 
Thea sinensis, 166 
Thebaine, 409 
Theine, 166 

Theobroma cacoa, 232, 486 
Theobrominas et sodii salicylas, 486 

sodiosalicylas, 486 
Theobromine sodiosalicylate, 486 
Theocin, 513 
Theophyllina, 513 

Therapeutical considerations, general, 17 
Therapeutics, definition of, 17 

limitations of, 29 



INDEX OF DRUGS AXD REMEDIAL MEASURES 



98: 



Thiocol, 513 
Thiosinamine, 513 
Thiosulphate of sodium, 490 
Thoroughwort, 289 
Thymol, 515 

iodide, 515 
Thymus glands, 516 
Thyroid gland, 516 
Thyroidectin, 519 
Thyroideum siccum, 516 
Thyroprotein, 518 
Thyroxin, 518 
Tinctura aconiti, 76 
aloes, 90 

et myrrhse, 388 
arnicse, 117 

florum, 117 
radicus, 117 
asafcetidae, 139 
belladonnse, 149 

fohorum, 149 
benzoini, 151 

composita, 151 
bryoniae, 164 
buchu, 166 
cahimbae, 173 

camphorae composita, 178, 418 
cannabis, 182 
cantharidis, 184 
capsici, 186 
cardamomi, 187 

composita, 187 
catechu, 294 
chloroformi et morphinse composita, 

218, 421 
cinchonse, 229 

composita, 229, 483 
cinnamomi, 230 
colchici, 244 

seminis, 244 
conii, 247 
convallariae, 248 
cubebse, 255 
digitalis, 264 
ergotee ammoniata, 272 
ferri chloridi, 339 

perchloridi, 339 
gambir composita, 294 
gelsemii, 296 
gentianse composita, 297 
guaiaci, 301 

ammoniata, 301 
hamamelidis, 305 
hydrastis, 311 
hyoscvami, 317 
iodi, 329 

fortis, 329 
mitis, 329 
jaborandi, 446 
jalapae, 344 
kino, 345 
lobelise, 357 

aether e a, 357 
moschi, 386 
myrrhse, 388 



Tinctura nucis vomicae, 407 
opii, 419 

ammoniata, 419 
camphorata, 418 
deodorati, 419 

physostigmatis, 441 

podophylli, 451 

pruni virginianae, 461 

quassia?, 462 

quininse, 227 

ammoniata, 227 

rhei, 465 

aromatica, 465 
composita, 465 
dulcis, 465 

sanguinariae, 476 

scillae, 492 

senegas, 482 

sennee composita, 483 

stramonii, 495 

strophanthi, 497 

sumbul, 502 

Valerianae, 529 

ammoniata, 529 

veratri \dridis, 531 

zingiberis, 297 
Tincture of apocynum, 114 

of cactus grandiflorus, 166 

of hops, 309 

of muriate of iron, 339 

Warburg's, 532 
Tinctures, 37 
Toast, watered, 659 
Toluene dichlor amine, 543 

sulphondichloramlne, 543 
Toluifera Pereirae, 142 
Tolysin, 403 
Tongue, Laborde's rhythmic traction of, 

in ac cidents by ether, 278 
Tonics, 54, 58 
Touchwood, 77 
Town's method of treating the morphine 

habit, 413 
Toxitabellae hvdrargvri chloridi corro- 

sivi, 374 
Transfusion, 633 

Lindeman method of, 635 

method of injection in, 635, 636 

Unger method of, 635 
Tribromomethane, 164 
Tribrom-tertiary-butyl-alcohol, 157 
Trichloracetic acid, 519 
Trichlorme thane, 199 
Trichlor-tertiary-butyl-alcohol, 197 
Trikresol, 519 
Trinitrin, 396 
Trinitrophenol, 441 
Trional (sulphonethylmethane), 520 
Trioxide, arsenic, 117, 124 

chromium, 218 
Triturates, 37 

tablet, 37 
Trituratio elaterini, 269 
Troches, 37 
Trochisci acidi tannici, 509 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Trochisci creta?, 170 

cubebse, 255 

ferri redacti, 342 

gambir, 294 

ipecacuanha?, 336 

magnesia?, 359 

mentha? piperita?, 427 

morphina? et ipecacuanha?, 336, 421 

potassii chloratis, 456 

santonini, 477 

sodii santoninatis, 477 

zingiberis, 297 
Trochiscus acidi benzoici, 151 
carbolici, 435 
tannici, 509 

catechu, 294 

guaiaci resina?, 301 

kino eucalypti, 289 

morphinse, 421 

et ipecacuanha?, 336, 421 

sulphuris, 501 
Tropacocaine, 520 
Tropic acid, 308 
Tropine, 308 
Truxillo coca, 232 
Trypsin, 424 
Tuberculin, 521 

B. E., 521 

bouillon filtrate, 521 

Denys', 521 

Moro test, 525 

old, 521 

ophthalmo-test, 525 

residuatum, 521 

skin test, 525 
Tully's powder, 421 
Turkish bath, 591 

home modification of, 593 
Turpentine, 526 

emulsion, 527 

liniment, 528 

oil of, 526, 582 

ointment, 527, 582 

stupe, 526 
Turpeth mineral, 382 
"Twilight sleep," 481 
Tylosin, 390 
Tyramine, 269, 272 



U 

Unger method of transfusion, 635 
Unguenta, 37 

Unguentum acidi borici, 156 
carbolici, 534 
gallici, 293 
salicyuci, 473 
tannici, 509 
aconitina?, 76 
antimonii tartrati, 106 
aqua? rosa?, 466 
atrophia?, 149 
belladonna?, 149 
cantharidis, 184 
capsici, 186 



Unguentum cetacei, 151 
chrysarobini, 218 
cocaina?, 237 
conii, 247 
creosoti, 254 
eucalypti, 289 
gallae, 294 

cum opii, 294 
glycerini plumbi subacetatis, 300 
hamamelidis, 305 
hydrargyri, 379 

ammoniati, 371 
dilutum, 379 
iodidi rubri, 375 
nitratis, 380 

dilutum, 380 
oleatis, 380 
oxidi flavi, 381 
rubri, 381 
subchloridi, 378 
iodi, 330 
iodoformi, 332 
petrolei, 430 
phenolis, 435 
picis liquida?, 506 
plumbi acetatis, 352 
carbonatis, 352 
iodidi, 352 
subacetatis, 353 
resina?, 462 
stramonii, 494 
sulphuris, 500 
zinci oxidi, 534 
Unit, antidiphtheritic, 547 
Unna's dressing, 535 
Urginea maritima, 491 
Uritone, 305 

Urotropin (hexamethylenamine), 305 
Ursin, 528 
Uva ursi, 528 
Uva? ursi folia, 528 



Vaccine, therapy, 638 

prophylactic, 642 

sensitized, 643 
Vaccines, lipo-, 643 
Valerate of ammonium, 100, 529 

of iron, 529 

of quinine, 227, 529 

of zinc, 529 
Valerian, 528 
Valeriana, 528 

officinalis, 528 
Valeriana? rhizoma, 528 
Valerianic acid, 528, 529 
Vallet's mass, 339 
Vapor acidi hydrocyanici, 314 

chlori, 176 

conii, 247 
Vaporization, 34 
Vaporizer, steam, 605 
Vaseline, 430 



INDEX OF DRUGS AND REMEDIAL MEASURES 



989 



Vasomotor depressants, 55, 58 

stimulants, 55, 58 
Vegetable astringents, 56 

cathartic pills, 245 

cathartics, 58 
Venesection, 644 
Veratri viridis rhizoma, 530 
Veratrina, 529 
Veratrine ointment, 530 
Veratroidine, 530 
Veratrone, 531 
Veratrum viride, 530 
Veronal, 142 

sodium, 142 
Veronica virginiana, 354 
Vienna mixture, 212 

paste, 457, 532 
Vinegar, 70 

of ipecac, 336 

of lobelia, 357 

of opium, 419 

of sanguinaria, 476 

of squill, 492 
Vinegars, 36 
Vinum colchici, 244 
seminis, 243 

ferri citratis, 343 

opii, 419 

picis, 510 

portense, 86 

quininae, 227 

xericum, 86 
Viriginia snake-root, 483 
Vitamines, 532 
Vitriol, oil of, 501 
Volatile oil of mustard, 386 
von Pirquet tuberculin test, 525 



W 

Wahoo, 289 
Warburg's tincture, 532 
Warming plaster, 184, 448 
Wash, black, 375 

yellow, 382 
Washed sulphur, 500 
Water of ammonia, 95 
stronger, 95 

barley-, 656 

bitter almonds, 88 

camphor, 178 

chloroform, 213, 218 

cinnamon, 230 

creosote, 254 

lead-, and laudanum, 352 

lime-, 174 

oatmeal-, 656 

peppermint, 427 

pimenta, 447 

rice-, 656 

rose, 466 

starch, 493 

tar, 510 
Watered toast, 659 



Waters, 36 

lithia, 622 

purgative, 623 

sulphur, 624 
Weights and measures, 37 

tables of relative, 40 

apothecaries', 38 

avoirdupois, 38 

metric, 39 
Wet cups, 582 
Whey curds and, 429 

wine-, 85, 657 
Whisky, 86 
White ginger, 297 

lead, 352 

mustard, 386 

oak, 462 

petrolatum, 430 

precipitate, 371 
ointment, 371 

wine, 86 
Whytt's tincture, 229 
Wild cherry, 460 
Wine, 85 

of colchicum, 244 
seed, 243 

of condurango, 246 

of iron, bitter, 343 

measure, 38 

mulled, 85, 659 

of opium, 419 

port, 86 

of quinine, 227 

red, 86 

of tar, 510 

whey, 85, 657 

white, 86 
Wines, 37 
Wintergreen, 295 
Witch-hazel, 304 
Wormseed, American, 191 

Levant, 476 



Xanthopuccin, 310 



Yellow gentian, 296 
jasmine, 295 
mercuric oxide, 380 
mercurous iodide, 381 
prussiate of potassium, 249 
pyoktanin, 383 
sulphate of mercury, 382 
wash, 382 
Yeo's creosote inhaler, 252, 609 
Yolk of egg, glycerite of, 300 
Young's rule for dosage, 45 



990 



INDEX OF DRUGS AND REMEDIAL MEASURES 



Zea mays, 493 
Zinci acetas, 533 

carbonas, 534 

prsecipitatus, 534 

chloridum, 534, 547 

oxidum, 534 



Zinci oxidum, venale, 534 

phenolsulphonas, 435, 547 
sulphas, 536 
sulphocarbolas, 435 
valeras, 529 

Zingiber, 297 

officinale, 297 



INDEX OF DISEASES AND EEMED1ES. 



ABORTION, 663 

Cascara sagrada, or compound liquorice 
powder as a laxative for associated con- 
stipation; if these fail, rhubarb or castor 
oil, 663 

Creolin (2 per cent, solution) should be 
injected after removal of the membranes, 
or if fever should follow, 665 

Curettement, 665 

Diet and hygiene, 663 

Elaterium, jalap, scammony, struchnine, i 
erigeron, cantharides, contraindicated, 
unless very necessary, 664 

Ergot and quinine, in small doses with 
perfect rest for one or two weeks, and I 
antiseptic irrigation as an after-treat- 
ment, 665 

Iodine, applied to the inner surface of j 
uterus, after removal of membranes, as 
a hemostatic and antiseptic 665 

Murphy drip if fever arises, 665 

Opium or morphine, best agents to quiet 
uterus if abortion threatens, 664 

Podophyllin, senna, salines in active doses, 
and aloes, not to be used if they can be | 
avoided, 663 

Quinine, useful in malarial poisoning, as a 
preventive; in other cases contraindi- ! 
cated, 664 

Saline purges contraindicated, except in 
plethoric women, 663 

Sponges should not be used as tampons, 
664 

Tampons of absorbent cotton, dusted with 
iodoform, followed later by ergot, if '' 
abortion is inevitable, 664 

Venesection, useful in plethoric women to | 
prevent, 664 

Viburnum prunifolium, fluidextract, dram 
| to 1 (2.0-4.0), taken during pregnancy 
as a prophylactic, 664 

ABSCESS, 665 

Alcohol, given with milk, in cold abscess, 
666 

Belladonna ointment, locally applied, 665 

Cod-liver oil, quinine and iron, useful in 
cold abscess, 666, 667 

Hydrogen peroxide, 3 per cent, solution, 
to wash out cavity of tubercular or slow 
abscess, 315, 666 

Incision, if pus forms, followed by irriga- 
tion, with phenol (1 : 20) or bichloride 
solution (1 : 5000) and antiseptic dress- 
ing, 666 

Iodine, locally applied, may abort, 667 

Iodoform gauze, packed into cavity, or 
ethereal solution injected after aspira- 
tion, and antiseptic dressing, useful in 
tubercular abscess, 667 



Lead-water, in early stage, to abort, 666 
Nitrate of silver, gr. 20 to 40 (1.3-2.6) to 
the ounce (30.0), locally applied, may 
abort, 665 
Phenol, minims 5 to 10 (0.3-0.6) of 2 per 
cent, solution, injected into gland threat- 
ening suppuration, 665 
Poultices to assist maturation, 666 
Prescriptions for tonics, in cold abscess, 666 
Quinine bihydrochloride solution to steri- 
lize cavity in amebic abscess of liver 
after aspiration of the pus, 226 

ACETONURIA. 

Chloroform contraindicated, 217 



ACIDITY. 

Ammonia, the most active remedy in gas- 
tric acidity, contraindicated if acute 
irritation exists, 95 

Bicarbonate of sodium in form of efferves- 
cing powder, valuable in gastric acidity, 
486 

Bismuth a slow and feeble antacid, 154 

Carbonate of calcium, precipitated, best 
antacid in intestinal acidity, 170 

Cerium oxalate, used in some cases of gas- 
tric acidity instead of bismuth, 191 

Charcoal, useful in some cases of "sour 
stomach," 187 

Lime-water, 174 

Liquor potassii hydroxidi, useful both for 
gastric and urinary acidity, 355 

Magnesium, a useful antacid, 360 

ACNE, 667 

Calx sulphurata, gr. T V to £ (0.006-0.008), 

in pill, thrice daily, in pustular acne, 

176, 667 
Cod-liver oil, if scrofulosis exists, 667 
Fowler's solution, often cures and prevents 

relapse, dose HI 1 to 3 (0.06-0.2) thrice 

daily, for a month or two, 667 
Green or Castile soap, used in face-bath 

night and morning, followed by brisk 

rubbing; if irritation ensues, simple 

cerate or emulsion of bitter almonds will 

relieve, 667, 668 
Ichthyol, 20 to 100 parts of lard, well 

rubbed in, when induration is great, 

319 ,668 
Mercurial ointment, to relieve induration, 

several days intervening between its 

use and that of sulphur, 668 
Phenol, touched to pustules after incision, 

668 
Phosphorus, especially useful in acne indu- 

rata, 439 

(991) 



992 



INDEX OF DISEASES AND REMEDIES 



Resorcinol, gr. 10 to 20 to the ounce (0.6- 
1.3 : 30.0) of lard, when induration is 
great, 668 

Saline purges, followed by cascara sagrada 
or similar remedy, to regulate bowels, if 
dependent upon obstinate constipation, 
667 

Sulphur, internally and as a wash or oint- 
ment, for women with disordered men- 
struation, prescription for, 500, 667 

ACTINOMYCOSIS. 

Potassium iodide, useful in full doses, 323 

ADENITIS, 668 

Ichthyol, prescription for, 668 

Iodine ointment and lard, equal parts, 
applied by inunction night and morning, 
or tincture, as a paint, stopping appli- 
cation on appearance of redness or fluc- 
tuation, 668 

Iron, syrup of the iodide, 1TI 5 to 20 (0.3- 
1.3), in children, 668 

Lancing, preferable to allowing abscess to 
break, 669 

Poultice, when redness or fluctuation ap- 
pears, 668 

Removal of gland by dissection, if enlarge- 
ment is scrofulous, 669 

Tonics, to improve systemic condition, 668 

ALBUMINURIA. (See Bright's 
Disease.) 

Cacodylate of iron, in albuminuria of 

tuberculosis, 339 
Calcium chloride or lactate, if due to 

alterations in the blood, 171 
Cantharides, useful in later stages of 

nephritis, 183 
Gallic acid, if due to atony of kidneys, 293 
Juniper, in albuminuria due to congestion, 

344 
Strontium lactate, if due to renal atony, 



ALCOHOLISM. (See Poisoning from 
Alcohol.) 

ALOPECIA, 669 

Chrysarobin, dram \ to 1 (2.0-4.0), to 
lanolin, 1 ounce (30.0), 669 

Corrosive sublimate, gr. 2 (0.12), to recti- 
fied spirit 1 dram (4.0) and oil of 
turpentine 7 drams (28.0), 669 

Liquor epispasticus, painted over bald spot 
after loose hairs have been depilated, 669 

Pilocarpine, locally applied, often stimu- 
lates new growth; too much causes small 
pustules around follicles; prescription 
for, 445 

AMAUROSIS AND AMBLYOPIA, 669 

Cauterization of nape of neck, 670 
Correction of optical errors, when arising 
from congenital trouble or non-use, 670 
Cups, wet and dry, 670 
Digitalis, in toxic cases, 670 
Electricity, constant current, 670 
Emmenagogues, if due to menstrual dis- 
orders, 670 
Iodide of potassium, 670, 671 



Metallo-therapy may be tried in hysteri- 
cal cases, 670 

Nitroglycerin, 670 

Nux vomica, in ascending doses in tobacco 
or alcoholic cases, 405 

Pilocarpine, in uremic, tobacco, or alcohol 
amaurosis, 445, 670 

Strychnine, hypodermically, after irrita- 
tion has subsided, 670, 671 

AMENORRHEA, 672 

Aloes, as a specific, when dependent upon 
constipation, atony of sexual system, or 
anemia, 90, 672 
; Apiol, 1U 3 to 10 (0.2-0.6), in capsule, 
thrice daily for a week before date of 
menstruation, 114, 673 

Arnica, 117 

Canthrides, as a stimulant, if due to atony 
or depression, 183 

Cimicifuga, fluidextract, 1U 30 (2.0), at the 
proper time for a flow, 219, 672 

Corpus luteum valuable, 250, 672 

Dewees' emmenagogue mixture, 673 

Dioxide manganese, gr. 1 to 3 (0.06-0.2), 
taken for two weeks before time of men- 
struation, 362, 672 

Eupatorium, in hot infusion, if due to cold, 
289 

Goodell's prescription for, 672 

Griffith's pills, largely used when dependent 
upon anemia, 339 

Hot sitz-bath, for several nights before 
period, mustard added often increases 
its efficacy, 673 

Iron and myrrh, a standard remedy if due 
to atony or anemia, 388 

Oil of rue, 1U 5 (0.3), in capsule, thrice 
daily, 673 

Potassium permanganate, useful, but infe- 
rior to dioxide of manganese, 430, 673 

Salines inferior to aloes if due to constipa- 
tion, 672 

Savine, Tfl. 5 (0.3), in capsule, thrice daily, 
to stimulate uterus, 477, 673 

Tansy, TTt 5 (0.3), in capsule, thrice daily, 
or in form of tansy tea, 509, 673 

ANAL FISSURE, 673 

Belladonna ointment or suppository in 
spasm of the sphincter due to fissure, 147 

Flexible collodion, painted over spot, may 
relieve, 674 

Ichthyol, pure, applied locally, 674 

Iodoform suppositories, gr. 10 (0.6), relieve 
pain of defecation; extract of hyoscy- 
amus, gr. \ (0.03) , to be added when 
there is spasm of sphincter, 332, 673 

Mineral oil, to relieve bowels, if sulphur 
cannot be used, 673 

Phenol, 1 drop, applied to fissure to effect 
cure; in addition, when hemorrhoids are 
present, a lotion of tannic acid, glycerin, 
and water, 673 

Potassium bromide, drams \\ to the 
ounce (6.0-30.0) of glycerin, locally 
applied to fissure by means of a brush, 
highly recommended, 673 

Sulphur, gr. 20 to 40 (1.3-2.6), combined 
with powdered cinnamon or aromatic 
powder, at night, to render passages soft, 
673 



INDEX OF DISEASES AND REMEDIES 



993 



ANAPHYLAXIS. 

Adrenalin, 505 

Atropine, in large dose, the best remedy, 
148 

ANEMIA, 674 

Aromatic mixture of iron, 338 

Arsenate of iron in anemia of chronic 

diarrhea, 338 
Arsenic, in full doses in pernicious anemia, 

677, very valuable in pernicious and 

malarial anemia, 120 
Bitters, simple or aromatic, in conjunction 

with iron, when stomach and intestines 

are atonic, 676 
Blaud's pill, 676 
Cacodylate of iron, when hemoglobin and 

corpuscles are lacking, 339 
Carbonate of iron, 339 , 676 
Chloride of iron, useful because of its tonic 

properties, 339 
Citrate of iron intramuscularly, 676 
Cod-liver oil, iron, and quinine, when 

anemia is due to childbearing and 

lactation, 676 
Copper arsenite, 250 
Diet and hygiene, 677 

Dried corpus luteum in chlorotic type, 298 
Iodide of iron, syrup of, largely used in 

strumous and scrofulous anemia, 326, 

341 
Iron, 337, 674, 675 
Mercury, bichloride or calomel especially 

valuable in syphilitic cases. Inunctions 

of mercurial ointment, once a day or 

every other day, of service, in all forms 

of anemia, 374, 676, 677 
Ovarian extract in chlorosis, 298 
Oxygen inhalations of value, 422 
Phenyl salicylate, when due to decomposi- 
tion-products, 474 
Quevenne's iron, 341, 676 
Quinine in malarial cases, and in tonic 

doses in all other anemias, 676 
Reduced iron, with laxatives and mineral 

acids for their effects on intestines and 

liver in uncomplicated cases, 341, 676 
Rest cure, 632 
Sodium cacodylate, 1 to 2 gr. (0.06-0.12), 

hyperdermically, 677 
Sulphate of iron in diarrhea with anemia, 

343, 676 
Transfusion in pernicious anemia, 633, 677 



ANEURYSM, 677 

Aconite, in full doses as a cardiac sedative, 
678 

Chloroform inhalation, if dyspnea is great, 
678 

Digitalis, contraindicated, 678 

Electrolysis, 678 

Iodide of potassium, in large doses, asso- 
ciated with restricted diet and rest in 
bed; more valuable in syphilitic than in 
other forms of the disease, 322, 678 

Morphine, gr. f (0.008), combined with 
hydrated chloral in sleeplessness due 
to pain, 678 

Veratrum, tincture, twice or thrice daily 
if heart is excitable and vascular ten- 
sion high, 531, 678 

63 



ANGINA PECTORIS, 679 

Alcohol, 679 

Benzylbenzoate, 151 

Digitalone, when heart is weak, 680 

Donovan's solution useful, 680 

Ether, hypodermically, often of service, 
679 

Hoffmann's anodyne, by mouth or hypo- 
dermically, gives good results, 307, 679, 
680 

Morphine, gr. J to § (0.015-0.03), hypo- 
dermically, when nitrite of amyl fails to 
relieve, 680 

Nitrite of amyl, inhalation of a few drops 

from handkerchief during attack, 101, 

679 

| Nitrite of sodium or potassium, 395, 679 

! Nitroglycerin, TU 1 (0.06) of the official 

spirit during attack, 396, 679 
i Prescriptions for use during and between 
attacks, 679, 680 

Stomach-pump, may be required when due 
to overloaded stomach, 680 

Tonics, combined with, careful diet and 
hygiene necessary to a cure, 680 

ANGIOMA. 

Carbon-dioxide snow 560 

ANOREXIA, 680 

Calomel, useful when following acute dis- 
ease; nitro-muriatic acid, however, gen- 
erally preferable, 377 

Capsicum, in convalescence, acts most 
favorably, 185 

Eupatorium, useful in, 289 

Gentian, 296 

Prescriptions for tonics, 681 

Quassia, especially valuable when follow- 
ing malarial fever, 461 

APHONIA. 

Chlorine gas has been used in aphonia due 
to cold, 176 

APOPLEXY, 681 

Atropine, hypodermically, if respiration 

fails, 682 
Calomel, gr. \ (0.015) every four hours, if 

symptoms of meningitis arise, 682 
Croton oil, TU 1 (0.06), with sweet oil, 1U 20 

(1.3), as a depletant cathartic, 681 
Diet, 682 
j Elaterium, gr. \ (0.01), as a depletant 

cathartic, 681 
I Ice to the head, 681 
Iodide of potassium, in large doses, when 

clot has firmly formed, to promote 

absorption, 682 
i Massage and electricity, applied to mus- 
cles to prevent atrophy; contraindicated 

if inflammation exists, 682 
Mercury in syphilitic cases, 682 
Mustard plaster to feet, or mustard foot- 
bath and ice to head, keeping head high 

and feet low, 681 
Stimulants contraindicated, 682 
Strychnine, hypodermically, if respiration 

fails, is also useful to stimulate trophic 

centers in cord, 682 
Venesection, usually contraindicated 645, 

682 



994 



INDEX OF DISEASES AND REMEDIES 



APPENDICITIS, 683 

Absolute rest necessary, 684 

Opium or morphine, to relieve excessive 

pain, 684 
Rules for treating, 684 
Surgical treatment, 684 

ARTHRITIS. 

Bicarbonate of sodium, applied to part on 
lint, to ally pain, 486 

Lactic acid bacilli used in rheumatoid ar- 
thritis, 347 

Lithium carbonate and citrate prevent 
deposit in joints from rheumatoid arthri- 
tis, 356 

Mustard plaster as a counterirritant, 387 

Phylacogens, 628 

Salicylic acid valueless in rheumatoid 
arthritis, 470 

Veratrine ointment, 530 

ASCARIS LUMBRICOIDES. 

(See Worms.) 

ASCITES. (See Dropsy.) 

ASPHYXIA, 685 

Ammonia, injected intravenously into leg 

to stimulate heart and respiration, 94 
Artificial respiration, Schafer's method, 

686; Sylvester's method, 686 
Electricity, only to be used as a peripheral 

irritant to restore respiration, 689 
Laborde's lingual traction of great value, 

689 
Oxygen inhalations, 423 
Rules regarding position of patient, 688 

ASTHENOPIA, 689 

Cannabis in retinal asthenopia, prescrip- 
tions for, 181 

Eserine or pilocarpine, weak solution, as a 
stimulant to ciliary muscles, 689 

Glasses, combined with prisms if necessary, 
to correct optical defects, 689 

Massage, rest, salt baths, strychnine, and 
iron, if due to neurasthenia, 690 

Strychnine or tincture of nux vomica in 
large doses to stimulate ciliary muscles, 
689 

ASTHMA, 690 

Aconite, in early stages, 75 
Adrenalin, very efficient, 504, 691 
Amyl nitrite, m 3 to 6 (0.2-0.4), on hand- 
kerchief, inhaled with care, relieves 

spasm, 102, 691 
Arsenic, internally or smoked in cigarettes, 

best remedy when mucous membrane 

is at fault, 122, 693 
Avoidance of proteins, 682 
Belladonna, combined with morphine, 

very useful, 147 
Benzyl benzoate, 151, 693 
Bromide of potassium or sodium gr. 30 

(2.0), half an hour before retiring, 693 
Bronchitis-tent, 694 
Chloral, rarely useful; if pushed, dangerous 

195 
Chloroform, inhaled, relaxes spasm; also 

useful in form of liniment applied to 

chest, to abort, 213, 691 
Climatic treatment, 624 



j Cocaine, applied to nasal cavities, if due 

to nasal disorders, 693 
i Coffee, a cup of strong black, during par- 
i oxysms, 168, 693 
| Compressed and rarefied air, 694 
Diet and hygiene, 693 
i Euphorbia pilulifera, i to 1 dram (2.0- 
4.0) of the fluidextract, 290, 692 
Gelsemium, 296 
j Grindelia, fluidextract of, 1U 10 to 30 (0.6- 
2.0), or leaves soaked in nitre smoked 
as cigarettes, or fumes of burning leaves 
inhaled, exceedingly useful, 301, 693 
Iodide of potassium, useful in bronchial, 

harmful in gastric, type, 322, 693 
Lobelia, tincture, TU 10 (0.6) every four 
hours, if attack threatens; in emetic dose 
if heart be strong, 357, 692, 693 
Morphine, hypodermically, gr. £ to i 
(0.01-0.015), alone or combined with 
atropine, 691 
; Nitrate of potassium alone or combined 
with belladonna, in form of cigarettes or 
inhalation of fumes often relieves, 458, 
692 
Nitroglycerin, serviceable, if bronchial 
mucous membranes are engorged, 397, 
691 
- Oil of amber, 92 

i Oxygen inhalations, when cyanosis is ex- 
I treme, 694 
Phylacogens, sometimes do great good, 693 
Physostigma, in bronchial asthma, to aid 

in expelling mucus, 441 
Sandalwood oil, useful in catarrhal cases, 

475 
Tobacco-smoking, often efficacious in 

patients not accustomed to it, 693 
Zinc oxide, prescription for, 535 

ATONY. 

Arsenic, in gastric and intestinal atony, 

120, 123 
Calumba, valuable in gastro-intestinal 

atony, following fevers, 173 
Capsicum, one of the best remedies in gas- 
tric atony due to debility and alcoholism 

84, 185 
Cardamom, with bitter tonics and mineral 

acid, in gastro-intestinal atony, 187 
Hydrastis, indicated in atony of mucous 

membranes, 310 
Leptandra, in duodenal atony, 354 
Mustard in gastric atony of drunkards, 

387 
Pepper, in atony of genito-urinary mucous 

membranes, 426 
Physostigma, in intestinal and vesical 

atony, 441 
Pituitrin used in atony of bladder, 450 
Pituitrin used by some in sexual atony of 

adults, 450 
Strychnine, in intestinal atony, 405, 406 



AURAL VERTIGO. 

| Pilocarpine, 445 

BALANITIS AND BALANOPOSTHITIS, 

801 
Astringent solutions, to cleanse parts, zinc 
chloride (gr. 4 to the ounce ([0.25-20.0]) 
boric acid (1 per cent.), phenol (1.5 per 
cent.) ; silver nitrate (gr. 1 to the ounce 
([0.06-30.0]) especially valuable, 801 



INDEX OF DISEASES AND REMEDIES 



995 



Lead-water, dilute, as a wet dressing, pre- 
ceded by astringent washes, in phimosis; 
if inflammation increases, circumcise, 
801 

Silver-nitrate stick, touched to ulcerations, 
801 

Tannin or zinc oxide, as a dusting-powder, 
after retracting prepuce and cleansing 
over absorbent cotton, 801 

BALDNESS. (See Alopecia.) 



BED-SORES, 694 

Aloes, glycerole of, as local application, 90 j 
Alum, with spirit of camphor and white ! 

of egg, locally applied, to prevent, 694 [ 
Gambir, with lead subacetate, locally ' 

applied, to harden skin, 694 
Glycerin, application daily after washing 

and rubbing part, to prevent, 299 
Incision, followed by irrigation, if sores 

tend to burrow, 695 
Iron, tincture of chloride, 1U 20 (1.3) every i 

four hours, as a tonic, 695 
Nitrate of silver (gr. 20 to the ounce [1.3: I 

30.01), painted over threatening part, to 

abort. If ulcers form and are sluggish, 

same solution may be used, 393, 695 
Salt and whiskv, rubbed over skin to har- j 

den it (2 drams to the pint [8.0:480.0]) 

694 
Scarlet red, 479 
Soap plaster, applied to sore after washing 

with bichloride solution (1: 5000) and 

dusting with iodoform, 486, 695 
Supportive measures and an increased 

amount of food, if sloughs are large, 695 
Zinc ointment, on squares of lint, some- \ 

times used in lieu of soap plaster, 695 

BILIOUSNESS, 695 

Aconite, antagonizes the poisoning alka- ! 

loids, which cause slow pulse, high arter- j 

ial tension, etc., 698 
Ammonium chloride, gr. 5 (0.3) thrice j 

daily, if associated with catarrh, 698 
Bromides and chloral, if nervousness and i 

irritation are present, 698 
Calomel, gr. £ (0.01) in powder every fif- | 

teen minutes until six are taken, fol- 
lowed in four hours by a saline, if stools 

be light, 370, 377, 697 
Chirata, extract of, gr. 5 (0.3), in hepatic j 

torpor, prescription for, 698 
Diet, 697 

Euonymus, extract of, gr. 3 (0.2), 697 
Horseback riding combined with gymnas- J 

tic movements especially valuable, 697 
Leptandra, when liver is torpid, 354 
Mustard plaster or cup to nape of neck, if j 

face is flushed; foot-bath also of service, 

698 
Nitro-muriatic acid, Tfl. 3 (0.2) thrice daily 

in water, of great service, 399, 697 
Podophyllin, gr. £ (0.01) if stools be dark, 

697 
Protiodide of mercury, gr. ^ to ^ { , (0.001- 

0.0015), in trituration thrice daily if due 

to catarrh, 698 
Salines, if attack is sudden, to sweep out 

poisonous matter, 697 



Salol (phenyl salicylate) or aspirin, in 10- 
gr. (0.6) doses, useful as an intestinal 
antiseptic, 698 

Stillingia, fluidextract of, dose, 20 drops 
(1.3) 697 

BLEPHARITIS, 698 

Boric-acid-lotion, when there is accom- 
panying conjunctivitis, 699 

Creolin, 1 to 2 per cent, solution, use as a 
wash, 251 

Methyl blue, 383 

Ointments, dilute citrine, Pagenstecher's 
ointment (yellow oxide of mercury, 1 gr. 
[0.06]), vaseline, 1 dram (4.0), dilute 
citrine ointment, aristol ointment, boric 
acid ointment, or a 3 per cent, milk-of- 
sulphur ointment, locally applied after 
removal of crusts, 698 

Silver nitrate, touched to crater-like ab- 
scesses, gives good results, 699 

Sodium bicarbonate or biborate solution, 
gr. 8 to ounce (0.5 : 30.0), to remove 
scabs and crusts, 698 

Zinc sulphate in 1 per cent, solution when 
due to Morax-Axenfeld bacillus, 698 

BOILS, 699 

Aluminum acetate useful, 92 

Belladonna, locally applied to relieve pain 
and inflammation, 699 

Calcium sulphurate, hastens pointing and 
prevents formation of new ones; useless 
in boils of diabetes, 176, 699 

Camphorated alcohol, applied over boils in 
formative stage, then wiped dry, fol- 
lowed bv camphorated oil to abort, 178, 
699 

Chloride of calcium, added to poultice, 
hastens maturation, 171 

Collodion, painted around inflamed spot, 
to abort, 244; if pus forms it may be 
absorbed, if not, evacuate by incision, 
699 

Egg-shells baked and eaten, for successive 
crops, 176 

Opium, locally applied to relieve pain and 
inflammation, 699 

Phenol, 5 per cent, strength, injected into 
apex of boil when formation is assured, 
or pure on end of wooden tooth-pick, 
to abort, 434, 700 

Phosphorus, 439 

Poultices, containing sweet oil and lauda- 
num, to assist maturation, 699 

Prescription for ointment, 699 

Silver nitrate (gr. 20 to the ounce [1.3: 
30.0]), painted over part, may abort, 
393, 699 

Sodium citrate solution, 1 per cent., on lint 
or gauze, to cause slough to come away, 
700 

Staphylococcic vaccine, 700 

BONE DISEASE. 

Calcium chloride, in deficient bone forma- 
tion, 171 

Iodide of iron, syrup of, if anemia exists, 
326 

Iodine ointment, diluted one-half, or tinct- 
ure, locally applied, 326 



996 



INDEX OF DISEASES AND REMEDIES 



BREASTS (INFLAMED), 700 

Aconite or veratrum, to depress circula- 
tion, 700 

Belladonna, internally or as an ointment, 
before and after inflammation, with cold 
compresses to breast, 148, 700 

Breast-pump, if milk continues to form, 
700 

Incise as soon as pus forms, 700 

Lead-water and laudanum, when connec- 
tive tissue is involved, 700 

Pressure bandage with ice-bag, 700 

Purges, mild saline, 700 



BREATH, FETID. 

Camphor, as mouth-wash, 178 

BROMIDROSIS. 

Belladonna, 147 

Borax of great value, 155 

Carbonate of calcium, precipitated, a use- 
ful application, 170 

Creolin ointment useful, 251 

Formaldehyde useful, 292 

Lead plaster and linseed oil, equal parts, 
applied every third day, 353 

Salicylic acid, used as a dusting-powder, 
prescription for, 472 

BRONCHITIS, 700 

Aconite, alone or combined with sweet 

spirit of nitre, in initial stage, 75, 701 
Amber, oil of, and olive oil (1:3), applied 
to back and front of chest, in infantile 
bronchitis, 92 

Ammoniac, useful in old forms devoid of 
inflammation, 95 

Ammonium carbonate, alone or with the 
chloride, especially useful in children; 
gr. 2 to 10 (0.12-0.6) in syrup of acacia, 
98 

Ammonium chloride in second stage to 
stimulate bronchial tubes, prescription 
for, 98, 704 

Apomorphine, 116 

Asafoetida, as a stimulating expectorant, 
139 

Belladonna, to check excessive secretion 
and stimulate respiration, 706 

Benzoic acid, 150 

Bronchitis-tent, 598, 702, 703 

Caffeine, or strong coffee, to stimulate res- 
piration if suffocation threatens, 706 

Camphor, in old or atonic cases, 178; lini- 
ment rubbed on chest, 701 

Cimicifuga in chronic bronchitis, 219 

Climatic treatment in chronic bronchitis 
624 

Codeine, recommended when cough is 
excessive, 138 ; 704 

Creosote, recommended in chronic bron- 
chitis, 252, 608 

Croton oil and sweet oil (half and half), 
sometimes applied to chest, 255 

Cubebs or copaiba, as expectorants, liable 
to derange stomach, 248, 255, 705 

Digitalis, if heart be feeble, 705 

Dover's powder, gr. 5 to 10 (0.3-0.6), with 
a hot drink, useful in early stage, 701 



Dry cups, if secretion is excessive, 706 
Ethyl iodide, 5 to 10 minims (0.3-0.6), 
inhaled from a handkerchief every few 
hours in the later stages to loosen secre- 
tions, 608, 704 
Eucalyptus oil, valuable in later stages, 
dose gtt. 1 to 5 (0.06-0.3), in capsule, 
every three hours, 288, 705 
Euphorbia pilulifera, i to 1 dram (2.0-4.0) 
of fluidextract, in chronic bronchitis, 
290 
Flaxseed tea, a useful demulcent, 291 
Gallic acid for profuse expectoration, 293 
Guaiacol vapor inhalations very valuable, 

302 
Hot foot-baths, with drinks of hot lemon- 
ade in early stages, 701 
Inhalations of steam from boiling water, to 
relieve bronchial soreness when counter- 
irritation fails, 606, 607, 608, 702 
Iodide of potassium, often useful when 
ammonium salts fail, contraindicated if 
secretion is excessive, 322 
Iodine externally, 327 
Iodoform, to lessen cough and fetid dis- 
charge, 332 
Ipecac, to unload stomach, 333; as a seda- 
tive expectorant, 334, 701 
Mustard plasters, 387, 701 
Myrrh with expectorant mixtures, useful 

in later stages, 388 
Oronasal respirator with terebene, iodide 

of ethyl, and chloroform, 704 
Oxygen, inhalations, when dyspnea is 

great, 422, 706 
Pitch, useful externally in chronic bron- 
chitis, 448 
Potassium citrate, with ipecac to aid for- 
mation of secretion, prescriptions, 456, 
701 
Potassium cyanide for excessive cough, 457 
Resin, inhalation of fumes, 462 
Sandalwood oil, in later stages, dose, 5 to 

10 minims, 475, 705 
Sanguinaria, 475 

Senega, a stimulating expectorant, in sub- 
acute and chronic stages, 482 
Squill, inferior to other drugs as an expec- 
torant, 492 
Steam inhalations, 608, 702 
Strychnine, to stimulate respiration, if 

suffocation threatens, 406, 706 
Tar, 509 

Tartar emetic, as an expectorant, gr. £ G 
(0.001) hourly, or 1 dram (4.0) of solu- 
tion (gr. | [0.03] to 4 ounces [120 cc]), 
or as an emetic in sthenic cases, 105 
Terebene, if ammonium chloride fails, 
dose, 5 to 10 minims (0.3-0.6), in cap- 
sule or emulsions; must be stopped if 
kidneys or stomach are irritated ; or used 
in an inhaler with equal parts of iodide 
of ethyl and chloroform, 511, 705 
Terpine hydrate or terpinol useful, 512, 

705 
Thiocol in chronic bronchitis, 513 
Turpentine inhalations or applied to chest, 
for children diluted one-half with sweet 
oil, 527 
Turpentine stupes, as counterirritants, 706 
Water, hot and cold dashes, if death is 
imminent from suffocation, 706 



INDEX OF DISEASES AND REMEDIES 



997 



BRONCHOCELE. 

Iodine efficient, 326 

Ointment of biniodide of mercurv, useful 

in, 375 
Potassium iodide internally, and tincture 

of iodine externally, 323 
Thymus gland in, 516 

BRONCHORRHEA. 

Alum, solution, gr. 20 to the ounce (1.3: 

30.0), applied in fine spray, 91 
Gallic acid, 293 
Strychnine, 406 

BRUISES. 

Alcohol, as a lotion, very useful, 81 

Arnica, 117 

Liquor plumbi subacetatis, locally applied, 
strength 1 to 4 ounces to the pint (30.0- 
120.0:480.0); contraindicated, if skin 
is broken; also useful as lead-water and 
laudanum (water 16, lead-water 4, lauda- 
num 1), 352, 417 

Warming plaster, 448 

BUBO. 

Compresses, kept wet with lead-water and 
alcohol, or soaked with ichthyol solu- 
tion, 1: 40, over which is laid a water 
bottle, 710 

Incision, at first sign of suppuration, fol- 
lowed by washing with bichloride solu- 
tion (1 : 1000), and dressed antisepti- 
cally, 710 

Phenol solution (gr. 8 to the ounce [0.5: 
30.0]), 10-minim injections, preceded by 
ether spray, 434 

BURNS AND SCALDS, 706 

Adrenalin chloride, dram 1 (4.0) of a 
1 : 1000 solution, in a pint of normal salt 
solution intravenously as a stimulant, 
707 

Ambrine, 708 

Bath in the treatment of, 707 

Bismuth hydroxide, 154 

Boric acid solution, a useful dressing, 156 

Calcium carbonate, precipitated, as a dres- 
sing, 170 

Camphor and phenol mixture useful, 178 

Carron oil in, 174, 291 

Castor oil, with a few drops of balsam of 
Peru or oil of eucalyptus, excellent, 190 

Chloretone in 10 per cent, ointment, 198 

Chloroform, ethyl chloride and ether to 
relieve pain when dressing, 207 

Cold cream, as a dressing, 466 

Dichloramine-T, 545 

Digitalone, gr. £ (0.03) with strychnine, 
gr. J s (0.003), in shock, if circulation 
fails to respond to less powerful stimu- 
lants, 707 

Hypodermoclysis useful, 601, 707 

Ichthyol ointment, 319 

Lead carbonate, as an ointment or, with 
linseed or other oils, as a dressing, 352 

Lime-water and linseed oil, equal parts, is 
a standard application, 174, 291 

Morphine and atrophine, gr. j to i (0.015- 

,^0.03) of former to gr. T J ff (0.0006) of 
latter, to allay pain, 706 

Opium useful, 417 



Orthoform, as an antiseptic anesthetic, 
421 

Paraffin dressing useful, 708 

Phenolized sweet oil, cosmoline, or simple 
cerate, useful application to counter- 
irritation burns, 434, 435 

Picric acid the best dressing, 442, 707 

Potassium citrate with sweet spirit of nitre, 
if urine is high colored, 708 

Prescription for, 707 

Salicylic acid, prescription for, 472 

Scarlet red useful in slowly healing burns, 
479 

Stimulants, if shock is severe, 707 

Zinc oxide, 535 

CANCER (GASTRIC). 

Arsenic small doses often repeated, to 
relieve vomiting, and pain in gastric 
cancer, 123 

Condurango, in the dose of 1 dram (4.0) 
of the fluidextract, 246 

Dionin as substitute for morphine, 267 

Hydrochloric acid, 312 

Lavage in, 616 

CANCRUM ORIS. 

Arsenic internally, 123 

Boric acid as a mouth-wash, 155 

CARBUNCLE. 

Aluminum acetate useful, 92 

Phenol solution (gr. 8 to the ounce [0.5: 

30.0]), hypodermic injections, to abort, 

434 
Phosphorus, 439 

CARIES. 

Lime salts, especially valuable in dental 
caries of nursing women, 172 

CATARRH OF ADt-PASSAGES. (See 
Nasal Catarrh.) 

Alum solution (gr. 20 to the ounce [1.3: 
30.0]), applied in fine spray, 91 

Apomorphine, in subacute and chronic 
forms, 116 

Arsenic, internally, 123 

Camphor of service in old and atonic cases, 
178 

CATARRH OF BLADDER. 

Ammonium benzoate, to render urine acid, 

96 
Juniper, a valuable stimulant, in chronic 

cases, 345 

CATARRH (DUODENAL). 

! Salol useful, 474 

CATARRH (INTESTINAL). 

j Ammonium chloride, useful in subacute 

types, 98 
Chlorate of potassium, injections (gr. 20 to 

the ounce [1.3 : 30.0]), in acute rectal 

catarrh, 455 
Iodide of potassium, if ammonium chloride 

fails to relieve, 322 
Leptandra, fluidextract, dose, 20 minims 

to 1 dram (1.3-4.0), 354 
Salol, 474 



998 



INDEX OF DISEASES AND REMEDIES 



CATARRH (RECTAL). 

Potassium chlorate, 20 gr. to the ounce of 
water, will often produce a cure after 
one or two injections, 455 

CEREBRAL DISEASES. 

Blisters, to nape of neck in cerebritis, 580 
Croton oil, in cerebral congestion, 254 
Elaterium, in cerebral congestion, 268 
Jalap may be used to deplete in cerebral 

congestion, 344 
Phosphorus, often of service in cerebral 

softening, 439 

CHANCRE. 

Nitric acid, used as a caustic, surrounding 

tissues being protected by oil, 394 
Salicylic acid, in soft chancres, 471 

CHANCROID, 708 

Acetanilid, used in a dry powder, 09 

Actual cautery, the most destructive caus- 
tic, 708, 709, 710 

Bismuth and zinc oxide, or calomel and 
bismuth are substitutes for iodoform, 
709 

Cocaine, 20 per cent, solution, to relieve 
pain of cauterization, 709 

Hot sitz-bath or general warm bath, 623, 
710 

Iodoform, the best palliative treatment, 
preceded by hydrogen peroxide spray 
1 : 4, followed by a spray of mercury 
bichloride 1 : 4000, 709 

Iodol or aristol, as a substitute for iodo- 
form 709 

Nitric acid, a good caustic, surrounding 
tissues being protected by oil, 394, 709 

Salicylic acid in powder or ointment, 471 

CHAPPING. 

Bismuth subnitrate, prescription for, 155 
Boric acid, prescription for, 156 
Calcium carbonate, precipitated, as a local 
protective in intertrigo of infants, 170 
Camphor, added to precipitated calcium 

carbonate, useful in intertrigo, 178 
Carbonate of zinc in infantile forms, pre- 
scription for, 534 
Cold cream, a useful application 466 
Light magnesia, as a dusting-powder in 

intertrigo, 359 
Lycopodium, as a dusting-powder, 358 
Starch, as a dusting-powder in intertrigo, 

493 
Zinc oxide, in powder form, useful in inter- 
trigo, 535 

CHILBLAINS. 

Alum, as a wash, 91 

Capsicum, tincture, pinated over parts or 

applied as a paper, prescription for, 185 
Ceratum resin®, 462 
Ichthyol ointment, 319 
Iodine ointment and lard, equal parts, 

give great relief, 327 

CHLOASMA OF PREGNANCY. 

Zinc oxide, prescription for, 535 

CHLOROSIS. (See Anemia.) 



CHOLERA (ASIATIC), 711 

Atropine and strychnine are useful, 713 
Camphor, in the form of camphorated wine 
of the greatest service in controlling 
cramps, 711, 712 
Enteroclysis, associated with hot baths, 

very valuable, 586 
Ether, subcutaneously, as a diffusible 

stimulant, 713 
Hypodermoclysis, very useful, 614, 712 
Intra-abdominal injection of normal sa- 
line, 610, 611, 712 
Intravenous saline injections, 614 
Kaolin in large doses, 711 
Phenyl salicylate and aspirin, 474, 712 
Potassium permanganate, in keratin- 
coated pills, probably even more useful 
than camphor, 712 
i Quarantine and strict hygiene, as pro- 
| phylactic, 711, 712 
Salol, one of the best remedies, 474, 712 
Sulphuric acid with camphor to control 
diarrhea, 502, 711 



CHOLERA INFANTUM, 713 

Arsenic, to check vomiting, prescription 
for, 715 

Beef-juice, as a food, especially valuable, 
714, 715 

Brandy, a drop or two with each teaspoon- 
ful of food, 714 

Buttermilk, diluted with water, when milk 
feeding is begun again, but is contraindi- 
cated if stools are acid in reaction, 715 

Castor oil, with paregoric, to empty bowels 
and allay irritation, 714 

Diet, 713, 714 

Enteroclysis, very valuable, 716 

Hypodermoclysis, or intra-abdominal or 
longitudinal sinus injections for col- 
lapse, 601, 716 

Intra-abdominal injection of normal saline, 
610, 611 

Iodoform and oil injections to relieve 
tenesmus, 332 

Irrigation of bowels, 716 

Lactic acid bacillus, Bulgarian, useful, 715 

Laudanum, 1U 10 (0.6), and starch-water, 
oz. 2 (60.0), by enema, and calomel, gr. 
rV (0.005), or gray powder, gr. | (0.01), 
by mouth, to control vomiting and purg- 
ing, if severe, 715 

Levulose or glucose, by bowel or intraven- 
ously, if patient is stuporous, 716 

Milk to be avoided at first, 714 

Mustard or spice plaster, over belly, always 
useful, 716 

Podophyllin, if stools are of peculiar pasty 
white color, 714 

Prescriptions for, 715, 716 



CHOLERA MORBUS, 717 

Camphor, 177 

Castor oil, with laudanum, to sweep out 

intestines, before diarrhea mixture is 

used, 717 
Ipecac, gr. 3 (0.2) every two hours, often 

of service, 335 
Morphine and atropine, if pain is severe, 

717 



INDEX OF DISEASES AND REMEDIES 



999 



Mustard or capsicum plaster, over abdo- 
men, 717 

Prescription for, 717 

Salol (phenyl salicylate), prescription for, 
474 

CHORDEE, 798 

Aconite, often relieves, 75 

Belladonna internally, and ointment ap- 
plied to under surface of penis, 147 

Bromide of potassium, dram 1 (4.0), 
with chloral, gr. 10 (0.6), at bedtime, 
repeated during night if necessary, 798 

Camphor with bromides, very useful in 
some cases, 177 

Canthrides, TTl 1 (0.06) thrice daily, 183 

Hot sitz-bath and steeping penis in hot 
water before retiring, relieves, 590 

Morphine, gr. \ (0.015), with atropine, gr. 
uV (0.001), hypodermically near peri- 
neum, to relieve, 798 

Opium or belladonna suppositories, to 
relieve, 798 

CHOREA, 717 

Arsenic, in ascending doses; discontinued if 
symptoms of poisoning ensue, 120, 717 

Bromides with chloral, when there is in- 
somnia, prescription for, 718 

Chloral, 195 

Chloroform inhalations when excessive, 
208 

Cimicifuga alone, or with arsenic, very 
useful, 219, 718 

Hot pack, at bedtime, if muscular jer kings 
are severe, 596, 718 

Monobromated camphor, 179 

Nitroglycerin, 396 

Novaspirin, 718 

Parathyroid gland, 426 

Salicylates of value, if associated with 
rheumatism, 718 

Silver nitrate, occasionally used, not 
reliable, 392 

CHOROIDITIS, 718 

Mercury, iodides and alteratives usually 

indicated, 719 
Tuberculin in suitable cases, 719 

CINCHONISM. 

Potassium bromide, as a preventive, 161 

CIRRHOSIS OF LIVER. 

(See Hepatic Cirrhosis.) 

COLDS. (See Coryza.) 

COLIC 

Asafcetida, useful in children, 139 

Benzyl benzoate in intestinal and uterine 
colic, 151 

Chloral and bromide, when severe in chil- 
dren; prescription for, 195 

Chloroform useful in renal or hepatic colic, 
213 

Ether internally, very useful, 282 

Hoffman's anodyne, 307 

Hyoscyamus, 316 

Matricaria, infusion, to prevent, in teeth- 
ing children, 363 

Mustard plaster, \ to \ strength, if skin is 
tender, 387 



i Peppermint in infantile colic, 427 
i Rue, as a carminative, 466 

COLIC (HEPATIC), 719 

Belladonna, in full doses, to relax spasm, 
147 

Benzoate of sodium, 720 

Calomel, if liver be very torpid, 720 

Chloroform or ether inhalations to relieve 
pain during spasm, 213 

Diet, 720 

Horseback riding, 720 

Hot applications over liver as a relaxant, 
719, 720 

Morphine, gr. \ to \ (0.015-0.03), with 
atropine, gr. r J-- ff (0.0006), hypodermi- 
cally, to relieve pain, 415, 719 

Olive or cottonseed oil, If pints (720.0) 
during attack; ether dram 1 (4.0) , 
may be added with advantage, 719 

Opium with belladonna to relieve pain 
and spasm, 415 

Salicylate of sodium, 720 

Turpentine, useful in, 719, 721 

COLIC (LEAD). 

Alum with morphine to allay pain, 91 

COLIC (RENAL). 

Belladonna, in full dose, 147 
Chloroform, a few inhalations often relieve, 

213 
Opium with belladonna relieves spasm and 

pain, 415 

COLLAPSE. 

Adrenaline intravenously, 505 

Atropine useful, 148 

Belladonna, as a vasomotor stimulant, 
148, 149 

Digitalis, 262 

Ether, by mouth, inhalation, or hypoder- 
mically, of great service, 282 

Hoffmann's anodyne in sudden collapse in 
infants, 307 

Hypodermoclysis in collapse of cholera, 
601 

Pituitrin as a useful circulatory stimulant, 
450 

Strychnine useful, 405 

CONDYLOMATA. 

Calomel, as a dusting-powder, often re- 
moves, 378 

CONGESTION. 

Croton oil, as a revulsive in cerebral con- 
gestion, 255 

Cupping, 582 

Digitalis, relieves stasis of congested lung 
in typhoid state, and congestion of the 
kidneys, 262 

Elaterium, in cerebral congestion, 268 

Ergot of service, especially with digitalis, 
271 

Glycerin, on cotton tampon, as a depletant 
in uterine congestion, 299 

Jalap, useful in plethora with cerebral con- 
gestion, 344 

Juniper often relieves congested kidneys, 
345 

Mustard, to nape of neck in cerebral con- 
gestion, 387 



1000 



INDEX OF DISEASES AND REMEDIES 



Mustard hot pack often useful in internal 
congestions, 597 

CONJUNCTIVA (BURNS OF), 722 

Atropine incorporated with liquid vaseline 

. instilled into eye, to prevent iritis, 722 

Goldbeaters' skin inserted between lids 

and eyeball, or breaking up granulation i 

prevents corneal inflammation, 723 
Neutralization of foreign matter, if acid or i 

alkaline, 723 
Sweet oil instilled into eye after removal 

of foreign matter, 722 

CONJUNCTIVA (CHEMOSIS OF), 727 

Astringent washes, especially alum, 727 
Nicking swollen tissue with scissors, 727 
Warm, moist compresses, 727 

CONJUNCTIVA (HEMORRHAGE 
BENEATH), 728 

Boric acid or cocaine wash, when conjunc- 
tival irritation exists, 728 

Massage of globe through closed lids, to 
aid absorption of blood, 728 

CONJUNCTIVITIS (CHRONIC), 725 

Acetate of zinc, gr. 1 to 2 (0.06-0.12) to the 

ounce (30.0), 533 
Boric acid wash (gr. 10 to the ounce [0.6: 

30.0]), with sodium biborate, gr. 4 (0.24), 

may be used as a soothing lotion; or salt, 

gr. 4 to the ounce (0.25: 30.0), may be 

substituted, 725 
Copper crystal, or a solution (gr. 1 to 3 to 

the ounce [0.06-0.2 : 30.0]), applied to 

diseased spot, if subacute, 250 
Correction of any refractive error, 725 
Lapis divinus, 725 
Tannin and glycerin (gr. 10 to the ounce 

[0.6 : 30.0]), as an application, 725 
Yellow oxide salve, or alum crystal, useful 

application, 381, 725 
Zinc oxide in powder, or the sulphate in 

the form of a wash, 535 
Zinc sulphate, gr. 1 to 2 (0.06-0.12) to the 

ounce, 725 

CONJUNCTIVITIS (DIPHTHERITIC), 

727 

Antitoxin injections the best treatment, 
727 

Atropine, instilled, 727 

Boric acid or bichloride solutions, fre- 
quently applied in early stages, 727 

CONJUNCTIVITIS (FOLLICULAR), 726 

Astringent and antiseptic lotions, 726 
Copper sulphate, as an ointment (gr. \ to 
the dram [0.03 : 4.0]), 726 

CONJUNCTIVITIS (GRANULAR), 726 

Adrenalin locally, 504 

Boric acid solution, as a wash in acute 

forms, 726 
Boroglyceride (20 to 50 per cent.), applied 

to chronic granulations, 726 
Copper citrate (5 per cent, ointment) is of 

service, 726 
Copper sulphate, crystal, applied to 

chronic granulations, 250, 726 



Corrosive sublimate solution (1: 8000) or 

cyanide of mercury (1 : 5000) and nitrate 

of silver, argyrol, or protargol may be 

employed to check purulent discharge, 

726 
Crushing granulations, often satisfactory, 

727 
Electrolysis, 727 

Excision of the fornix conjunctiva, 727 _ 
Glycerole of tannin, applied to chronic 

granulations, 726 
Jequirrty infusion (3 per cent.) painted on 

inner side of eyelids, of use, 344 
Leeches to temple, to reduce inflammation 

in acute stage, 619 
Phenol, hydrastin, iodide of silver, ich- 

thargon, 2 to 3 per cent, and ichthyol, 

have been employed, 727 
Scarification followed by brushing the 

conjunctiva with a solution of bichloride 

of mercury, 727 
Silver nitrate, stick or solution (gr. 10 to 

the ounce [0.6 : 30.0]), applied daily, if 

there is discharge ; neutralize excess with 

salt solution, 393, 726 
Yellow oxide of mercury ointment with 

lard, equal parts, in chronic types, 381 
X-rays and radium recommended by some, 

727 

CONJUNCTIVITIS (LACRIMAL). 

Treatment same as for chronic type. 

CONJUNCTIVITIS(MUCOPURULENT) . 

Treatment same as for purulent type. 

CONJUNCTIVITIS (PURULENT), 723 

Argyrol and protargol as substitutes for 
silver nitrate, 117, 723 

Atropine if corneal ulcer appears, 724 

Creolin solution, 1 per cent. 251 

Glycerite of boroglycerin, 300 

Iced compress in early stage, to reduce 
inflammation, 724 
; Permanganate of potassium 1: 5000, in 
copious irrigations, four or five times a 
day, 724 
j Silver nitrate, stick or solution (gr. 10 to 
the ounce [0.6 : 30.0]), touched to lids 
after they have been cleansed of pus, 
excess neutralized with salt solution; 2 
per cent, solution dropped in newborn 
infant's eyes to prevent, 393, 723, 724 

Silvol, 25 per cent, solution, may be used, 
485 

CONJUNCTIVITIS (SIMPLE), 721 

Alum crystal applied when it tends to 

become chronic, 722 
Argyrol, 10 to 25 per cent, solution, in 

place of silver nitrate, 722 
Atropine usually unnecessary unless cor- 
neal ulcer is present, 722 
Boric acid lotion (gr. 10 to the ounce [06- 

30.0]), 155, 721 
Compresses of ice to allay inflammation, 

722 
Leeches to temple or back of ears, 619 
Mercury bichloride solution (1: 10,000), or 

mercurophen (1 :8000), if discharge is 

great, 721 
Methyl blue, 383 



INDEX OF DISEASES AND REMEDIES 



1001 



Poultices and bandages contraindicated, 
722 

Protargol, 1 to 5 per cent, solution, 460.722 

Protargol and argyrol, 10 to 25 per cent, 
solution, in place of silver nitrate, 722 

Silver nitrate/ solution (gr. 2 to 5 to the 
ounce [0.12-0.3 : 30.0]), if there is muco- 
purulent discharge. If discharge is 
excessive, employ gr. 10 to the ounce 
(0.6: 30.0), and neutralize excess with 
salt solution or wash with tepid water, 
721 

Smoked glasses, 722 

Sodium biborate, gr. 4 to 8 to the ounce 
(0.25-0.5: 30.0), 722 

Tannin and glycerin (gr. 10 to the ounce 
[0.6 : 30.0]), or alum crystal if there is a 
chronic tendency, 722 

Zinc oxide, 535 

Zinc sulphate solution (gr. 1 to 2 to the 
ounce [0.06-0.12 : 30.0]), alone or with 
boric acid, if there is chronic tendency, 
536, 722 

CONJUNCTIVITIS, VERNAL, 727 

Adrenalin chloride, 1 : 10,000, used per- 
sistently, is useful, 727 
Fibrolysin applications valuable, 727 
Radium is valuable, 727 



CONSTIPATION, 728 

Abdominal supporting belt in constipation 
wiCh enteroptosis, 728, 732 

Agar-agar when the stools are dry, 77, 730 

Aloes, 89, and podophyllin, with other 
drugs, useful for temporary use; pre- 
scription for, 731 

Belladonna, 148 

Benzyl benzoate, 20 1U of a 20 per cent, 
solution, in spastic states, 151, 732 

Bryonia, when intestinal secretions are 
deficient, 165 

Calomel, 374 

Cascara sagrada, the best curative agent, 
dose 1U 10 to 40 (0.6-2.6) of fluidextract, 
or dram 1 (4.0) to 6 (24.0) of cordial, 

188, 731, 732 

Castor oil ultimately harmful in all cases, 

189, 730 

Colocynth, jalap, or senna, not to' be used 

constantly, 731 
Compound cathartic pill, sometimes neces- 
sary, 732 
Diet of extreme importance, 728, 729 
Enemata, as a routine treatment, harmful, 

732 
Glycerin, suppositories or enemata, often 

used, 299, 732 
Gymnastic movements, horseback riding, 

or massage, with regulated diet, 729 
Hunyadi, Pluto, or Abilena waters, when 

plethora exists, 730 
Leptandra in intestinal atony, 354 
Liquid petrolatum when stools are dry, 

730 
Lobelia, in combination with cascara 

sagrada, useful in atonic forms, 357 
Magnesium sulphate by the mouth or by 

enema, 360, 730 
Manna, as a laxative fruit for adults, or 

drams 1 to 2 (4.0-8.0) to bottle of 

milk, for infants, 363 



Mercury, as an habitual purgative, harm- 
ful, 368, 375, 731 

Opium in reflex constipation, 416, 732 

Phenolphthalein, 1 to 2 grains (0.06-0.12), 
an excellent laxative in habitual consti- 
pation, 435, 731 

Phosphate of sodium, useful in rickety 
children, gr. 5 to 10 (0.3-0.6); or gr. 
30 to 60 (2-4) in adults, 489, 731 

Pilula earthartica vegetabilis, may be 
required, 732 

Rhubarb, usually harmful in children; in 
some cases useful, 464, 731 

Salines, simply to unload bowels, 730 

Seidlitz powder, 481 

Senna, said to be useful in constipation of 
pregnancy, particularly if combined 
with cascara sagrada, 482 

Soap suppositories, useful in children, 485 

Stillingia, recommended when habitual; 
prescriptions for, 493 

Sulphur, especially valuable if hemorrhoids 
are present, 500 

Tobacco, sometimes used, 732 

CONVULSIONS. 

Allium, as a poultice, over spine or feet in 
infantile spinal or cerebral convulsions 
87 

Amyl nitrite, 101 

Chloral with bromide, in infants; also use- 
ful alone in uremic and puerperal con- 
vulsions, if no acute renal trouble exists, 
159, 195 

Chloroform, 208 

Intravenous saline injections, 614 

Spinal puncture in, 621 

CORNEAL OPACITIES. 

Dionin, of service in opacities of recent 
origin, 861 
I Electricity, 860 
! Fibrolysin, 860 

j Massage with yellow oxide of mercury 
! salve, 860 
Subconjunctival injections of physiological 

salt solution in corneal nebula?, 860 
Thiosinamine has been used, 514, 860 

CORNS, 733 

! Fowler's solution, locally applied, 123 
Lactic acid often of service, 733 
Salicylic acid, the best application, formula 

for, 471, 733 
Silver nitrate solution (gr. 60 to the ounce 

[4.0 : 30.0]), applied to soft corns every 

four or five days, 733 

CORYZA, 733 

! Aconite, useful in early stages, 75 
Adrenalin locally to relieve engorgement, 

504, 733 
Allium, as a poultice to breast, or in emul- 
sion or boiled in milk, for children, 87 
Antipyrine solution gr. 2 to 4 to the ounce 
(0.12-0.25:30.0) as a spray, preceded 
by a cocaine spray, 111, 733 
Arsenic, taken for months, often cures 

persistent colds, 123 
Belladonna in, 148, 734 
Bromides useful in headache, 734 



1002 



INDEX OF DISEASES AND REMEDIES 



Camphor, as a snuff, or inhalation of spirit, 
or fumes, when sneezing and lacrima- 
tion are excessive, 178 

Cocaine, a few minims of a 4 per cent, solu- 
tion dropped into nostril, followed by 
lotion (see Prescription) with atomizer, 
235, 733 

Cubebs, as a snuff during stage of secretion, 
255 

Glycerin, applied alone by brush or spray, 
often of service, 299 

Hamamelis, useful after acute stage is past, 
304 

Hot mustard foot-bath with hot draught 
or Dover's powder, followed by rest in 
bed, may relieve, 734 

Inhalation of tincture of iodine, 329 

Iodide of potassium at beginning will often 
abort, 323 

Menthol, very useful, 428 

Prescription for wash, 733 

Prescriptions for nebulizer, 610 

Quinine, internally, combined with chlor- 
ide of ammonium, useful after secretion 
is established, 734 

Silvol in early stages, 485 

Sodium bicarbonate, gr. 30 (2.0) every two 
hours for three doses, of much benefit, 
734 

Sweet spirit of nitre, 507, 734 

Tartar emetic, 105 

Urotropin useful to abort acute coryza, 306 

COUGH. 

Acacia, as a mucilaginous drink with flax- 
seed and liquorice, to loosen hacking 
cough, 65 

Almond, essential oil of, in emulsion, as a 
demulcent in cough of phthisis, 88 

Belladonna, the best remedy in nervous 
cough, 148 

Cannabis, a useful adjunct to cough mix- 
tures, 180 

Chloroform, useful, added to cough mix- 
tures for irritant cough, 213 

Codeine, useful in nervous cough, 238 

Dionin, i to f gr. (0.015-0.045), to relieve 
excessive cough, 267 

Flaxseed tea, alone or with paregoric, a 
useful demulcent in excessive cough, 291 

Gelsemium in nervous cough, 296 

Heroin, 305 

Honey, 308 

Hydrocyanic acid, highly recommended, 
prescription for, 313 

Hyoscyamus in nervous cough, 316 

Iodine, as a paint over supraclavicular 
spaces, in irritative cough, 326 

Ipecac, in spray, useful in chronic winter 
cough, 335 

Morphine in wild-cherry syrup useful in ir- 
ritative cough and when cough is greater 
than necessary to expel mucus, 416 

Paregoric (1 dram [4.0]), in hot water, 
from which the steam is inhaled, useful 
in irritative form of cough, 416 

Sandalwood oil for excessive cough follow- 
ing influenza, 475 

Syrup of wild cherry, as a vehicle for cough 
mixtures, 461 

CRAMPS. 

Belladonna, internally, or locally as a 
liniment, 147 



Chlorodyne, for stomach cramp, 198 
Ginger, especially useful in menstrual 
cramp due to cold, 297. (See Dysmen- 
orrhea.) 

CRETINISM. 

Thyroid gland, very useful, 517 
Thyroxin, T fo to jh gr. (0.0002-0.0004), 
518 

CROUP (MEMBRANOUS). 

(See Diphtheria.) 

CROUP (SPASMODIC), 734 

Aconite useful, 75. 

Amyl nitrite, inhalations, if paroxysms is 

severe, 102, 735 
Belladonna, bromides, chloral, or opium in 

small doses at bedtime, as a preventive, 

734 
Bromides and lactucarium, 735 
Bronchitis-tent, 734 
Cold cloth around neck, and child placed 

at once in hot bath, air of room being 

moistened by steam, 735 
Hot compress is very useful, 590 
Iron and arsenic as tonics if child is anemic 

and rachitic, 734 
Menthol, useful, 429, 606, 735 
Prophylactic measures, 734 
Sanguinaria, as an emetic, unfavorable, 

475 

CYSTITIS (ACUTE), 735 

Aconite in full dose, with sweet spirit of 
nitre and potassium citrate, if there is 
fever; prescription for, 735 

Argyrol, 10 to 25 per cent, solution, may 
be injected into the bladder, 117, 736 

Belladonna, alone or with aconite, espe- 
cially useful if due to cold; dose, TTX 15 
to 20 (1.0-1.3) thrice daily, 735 

Boric acid, to render urine acid, 156 

Cannabis, preferable to opium for reliev- 
ing pain, 181, 736 

Copaiba, useful in subacute stage, 248 

Creolin, as a vesical wash (1 to 2 per cent, 
solution) in cystitis of women, 251 

Flaxseed tea, as a demulcent, 291 

Hot compress over bladder, should not 
contain irritants, 735 . 

Hot sitz-bath and enemata to relieve bear- 
ing-down pain, 736 

Hygienic measures, 736 

Laudanum, TC[ 30 (2.0), to starch-water oz. 
2 (60.0), in enema, to relieve bearing- 
down pain, 735 

Leeches to perineum or cups to sacrum, 735 

Liquor potassii hydroxidi, 1U 5 (0.3) every 
four hours, if urine is acid, 735 

Opium, belladonna, or iodoform supposi- 
tory, to allay bearing-down pain, 416, 
736 

Quinine, contraindicated, 736 

Salines, in early stage to evacuate bowel, 
736 

Salol (phenyl salicylate), gr. 10 (0.6) thrice 
daily, if inflammation becomes purulent, 
736 

Urotropin (hexamethylenamine) gr. 5 to 
10 (0.3-0.6) in capsule, three or four 
times a day, in ammoniacal cystitis, 306, 
736 



INDEX OF DISEASES AND REMEDIES 



1003 



CYSTITIS (CHRONIC), 73G 

Arbutin, gr. 3 to 5 (0.2-0.3), or fluidex- 
tract of buchu or uva ursi, \ to 1| 
drams (2.0-6.0), to improve vesical 
mucous membrane when inflammation 
is of subacute type, 528, 737 

Benzoate of ammonium, gr. 10 to 20 
(0.6-1.2); acid sodium phosphate, gr. 
20 to 40 (1.2-2.4); or urotropin, gr. 10 
(0.6), to render urine acid, 96, 737 

Benzoic acid useful when urine is alkaline 
and loaded with phosphates, 150 

Buchu, 165, 737 

Cantharides, 183, 737 

Chloretone solution useful, 737 

Grindelia, as a vesical stimulant, 301 

Juniper of value, 345 

Mercurol solution, 737 

Mercury bichloride solution (1 : 10,000), as 
an injection to cleanse bladder, 737 

Myrrh, often of service, 388 

Opium suppositories, gr. \ to f (0.015- 
0.03), very useful, 416 

Pareira, 426 

Potassium salts, except bitartrate, to ren- 
der urine alkaline when mucus is exces- 
sive, 737 

Salol (pheynl salicylate), 737 

Sandalwood oil, 475, 737 

Silver nitrate solution (gr. 1 to oz. 4 [0.06 : 
120.0], increased gradually to gr. 2 to 
oz. [1 0.12 : 30. 0J), as an injection when 
discharge is mucopurulent, followed by 
salt solution if pain is severe, 737 

Strychnine and cantharides, when vesical 
atony is great, 737 

Turpentine, oil of sandalwood, cubeb, or 
copaiba, useful when vesical atony is 
great, 737 

Urotropin or uritone, 306, 736, 737 

Uva ursi, 528, 737 

Vaccines, 736 

DEAFNESS. 

Thiosinamine when due to thickening of 
drum or fixation of aural bones, 514 

DEBILITY. 

Arsenic, with bitter tonics, very useful, 120 

Calomel, in debility of children, often re- 
lieves, 376 

Capsicum for gastric atony, 185 

Eupatorium, a good tonic, 289 

Phosphorus, of service in sexual debility, 
439 

Vitamines in general debility in children, 
532 

DELIRIUM TREMENS. 

Apomorphine to produce nervous quite, 

116 
Chloral, of great service used cautiously, 

195 
Croton oil, 255 
Hops, 309 

Hyoscine, in insomnia, 317 
Monobromated camphor, when nervous 

twitching is troublesome, 179 
Valerian with morphine, frequently used, 

529 

DERMATITIS. 

Chloride of ammonium lotion, when due 
to ivy-poisoning, 98 



Grindelia robusta, in solution, one of the 
best lotions in ivy poisoning, 301 

Lead acetate, useful in ivy-poisoning, 352 

Lead-water and laudanum in ivy-poisoning, 
352 

Lobelia infusion as a lotion in ivy-poison- 
ing, 357 

Sodium thiosulphate prescription, 490 

DIABETES INSIPIDUS, 738 

Arsenic, 122 

Ergot, in combination with bromide of 

sodium, 271 
Opium, 417 
Pituitrin, 450, 738 

Rhus aromatica, highly recommended, 465 
Valerian in full doses, 500, 730, 738 

DIABETES MELLITUS, 738 

Almond bread, bran bread, or artificial 

milk, as a food for diabetics, 87, 657 
Alum,. 91 
Antipyrine, 111, and arsenate of sodium 

and carbonate of lithium when of gouty 

origin, 111, 743 
Carbonate of sodium by intravenous injec- 
tion in diabetic coma, 745 
Codeine, in ascending doses, beginning 

gr. 1 to 5 (0.06-0.3) thrice daily, 238, 

743 
Colchicum and iodides, in gouty types, 743 
Dextrose in solution may be given freely, 

745 
Diet, 738, 739, 740, 741 
Ether hypodermically, to support heart 

in diabetic coma, 745 
Glycerin or saccharin, as sweetening agents 

to replace sugar, 299, 467 
Hvpodermoclysis, 601, 745 
Iodol, gr. 2 to 6 (0.12-0.4) thrice daily, 

recommended, 332 
Intravenous saline injections, 614 
Iron, lacto-phosphates of lime and sodium, 

strychnine, and astringents, if cachexia 

comes on, 744 
Levulose, as a substitute for sugar, 354, 

745 
Lime-water, 174 
Lithium carbonate or citrate, with arsenic, 

very useful, if due to gout, 356 
Morphine, very useful in ascending doses, 

743 
Non-purgative alkaline water, to allay 

thirst, 744 
Opium, gr. \ to \ (0.015-0.03) thrice daily, 

largely used, 417, 743 
Pancreas of doubtful value in pancreatic 

diabetes, 298, 424 
Pancreatin, when the disease is due to a 

lesion of the pancreas, 424 
Purgatives, restricted diet, and exercise, if 

due to high living and sedentary habits, 

745 
Saccharin in place of sugar in beverages, 

467, 745 
Salicylates and iodide of potassium, if due 

to rheumatic or gouty taint, 743 
Sodium bicarbonate, oz. \ to 1 (16.0—30.0) 

daily when coma is feared, because of 

increase of acetone in urine, 745 
Taka-diastase diminishes polyuria, 256 
Transfusion, in diabetic coma, 745 



1004 



INDEX OF DISEASES AND REMEDIES 



DIARRHEA, 745 

Allspice, 447 
Arsenic, 123 
Belladonna, may be used in serous types, 

147 
Beta-naphthol-bismuth, in serous and fer- 
mentative types, 151 
Bichloride of mercury, gr. 2 off (0.0003) 

hourly, if stools be slimy and bloody, 

374, 749 
Bismuth, with phenol, gtt. 1 to 2 (0.05- 

0.1), highly recommended in serous and 

summer diarrhea, 154, 433, 748 
Cajuput, m 10 to 20 (0.6-1.3), in serous 

forms, 169 
Calomel, followed by a saline, useful in 

sthenic cases of summer diarrhea, 376, 

747 
Calumba, in summer and serous diarrheas, 

prescription for, 173 
Camphor, useful in serous, but never in 

mucous types, 177, 747 
Castor oil, with laudanum and sodium 

bicarbonate, to unload bowel and render 

it alkaline, 189, 746, 748 
Chalk mixture, with kino and gambir, in 

serous diarrheas, prescription for, 170 
Charcoal, useful in acid and fermentative 

types, 187 
Chirata, nitro-muriatic acid, or, better 

still, nitric acid and cardamom in 

mucous type, prescription for, 746 
Chlorate of potassium in acute rectal 

catarrh with mucous diarrhea, 455 
Chlorodyne, largely used in serous types, 

198 
Chloroform, with astringents and opium, 

very useful after removal of irritant 

cause, 213, 747 
Cinnamon, as a stimulant in serous types, 

230 
Cloves, to prevent griping, 232 
Copper sulphate, gr. \ (0.015), with opium, 

gr. 1 (0.06), in pill, if due to ulceration, 

249 
Creolin in entero-colitis, 5 : 1000 of water, 

251 
Diet for summer diarrhea, 746, 748 
Enteroclysis, when mucous form becomes 

chronic, 586, 749 
Ergot, sometimes useful in serous types, 

271 
Gallic acid, 293 
Gambir, alone or with opium, in serous 

types, prescription for, 294, 747 
Ginger, a good addition to diarrhea mix- 
tures, 297 
Guaiacol carbonate, in fermentative forms 

of, 303 
Hematoxylon, useful in children, because 

of agreeable taste, 304 
Hope's camphor mixture, in serous and 

choleraic types, 309 
Ipecac, gr. \ to i (0.015-0.03), thrice daily, 
useful in summer diarrhea of children, 

335 748 
Kino, 'formula for, 345, 747 
Lactic acid bacillus useful in infantile diar- 
rhea with putrefactive changes in the 
bowel, 347, 748 
Lead acetate, with opium and camphor 
in serous types, prescription for, 352, 746 
Mercury, with chalk or calomel, in hepatic 
disorder, 379, 747 



Morphine, gr. & to ^ (0.0008-0.0012), 
hypodermically, often checks summer 
diarrhea in children, 417 

Mustard plaster or other counterirritants 
to abdomen, 746 

Nitrate of silver and hyoscyamus, or lead 
acetate and opium, in mucous diarrhea, 
prescription for, 746, 749 

Nitro-muriatic acid or podophyllin, gr. 
A to 3*0 (0.0012-0.0015), in summer 
diarrhea, if duodenum is at fault, 399 
746, 748 

Nutmeg, useful in serous types, 403 

Opium, 417, 746 

Pancreatin in lienteric diarrhea, 424 

Pepsin with hydrochloric acid in summer 
diarrhea, if gastric digestion is deficient, 
748 

Phenol, especially useful as an intestinal 
antiseptic, 433 

Phenolsulphonate of zinc, 2 grains (0.12), 
every three hours, of service in summer 
diarrhea, 436, 747 

Phosphate of sodium, lime salts, and com- 
mon salt in summer types, if rickets is 
present, 489, 748 

Podophyllin, 451 

Precipitated carbonate of calcium, in 
serous diarrhea, 170 

Raspberry-leaves, used in domestic medi- 
cine, 466 

Rhubarb, often useful, preceding direct 
treatment in summer diarrhea, 464 

Salol (phenyl salicylate) combined with 
chalk mixture, 474, 747 

Sulphate of iron in chronic forms, 343 

Sulphuric acid, especially valuable in 
serous types, prescription for, 502, 747 

Tannic acid, in atonic or serous types, 508 
I Tar mixture, highly recommended in ob- 
stinate types, formula for, 509 
i Zinc oxide, in summer types, 535 
I Zinc sulphate, 2-grain (0.12) pills, espe- 
cially useful with opium or podophyllin, 
g r - bV (0.001), in serous types, 536 

DIARRHEA (CHRONIC), 750 

Ammonium chloride, gr. 5 (0.3) every four 
hours, best remedy in persistent catar- 
rhal states, 750 

Arsenic, 123 

Bismuthi et ammonii citras, in chronic 
serous types, 152 

Diet, 750 

Ipecac, gr. 3 (0.2), every two hours, of 
service, 335 

Iron sulphate, gr. 5 (0.3), in pill, in chronic 
types, 343, 751 

Nitric acid, with a bitter tonic, useful in 
green diarrhea of children, combined 
with pepsin, 394 

Operative procedures when due to lesions 
of the rectum, 751 

Podophyllum, 451 

Potassium iodide, gr. 3 to 5 (0.2-0.3), if 
catarrhal state is obstinate, 750 

Silver nitrate in pill form, or in other cases 
rectal injections of this drug, gr. 2 to 
oz. 1 (0.12-30.0), followed by iodoform 
suppository, of greatest benefit, 750 

DILATATION (GASTRIC AND INTES- 
TINAL). 

Physostigma with nux vomica, 441 



INDEX OF DISEASES AND REMEDIES 



1005 



DIPHTHERIA, 751 

Alum, 91 

Antistreptococcic serum, 554 

Antitoxin, excels all other; 2000 to 5000 
units should be thrown into an area 
where there are loose connective tissues. 
A special syringe is used for this purpose, 
and should be perfectly aseptic, 549, 752 

Borax solution, as a gargle in, 155 

Bronchitis-tent in laryngeal cases, 608, 757 

Chlorate of potassium, contraindicated for 
internal use because of danger to the 
kidneys. It may be applied upon a 
swab, 455, 757 

Hypodermoclysis, 757 

Ice-bags to the neck, ice in the mouth, and 
antitoxin internally, if glandular sup- 
puration threatens, 757 

Irrigation of the nasal chambers useful in, 
751 

Lime-water as spray or application very 
useful in, 174 

Loffler's application (menthol, dr. 2| 
[10.0], dissolved in dr. 9 [34.01 of toluol; 
add dr. 1 [4.0] of liquor ferri chloridi and 
absolute alcohol, fl. oz. 2 [60.0]), 751 

Milk diet, 756 

Monsel's solution, as a topical application, 
342 

Oxygen inhalations, strychnine, and atro- 
pine if suffocation is imminent. Intu- 
bation or tracheotomy may be necessarv, 
757 

Peroxide of hydrogen is the best local ap- 
plication. May be applied on a swab or 
as a spray (1 : 4), to remove false mem- 
brane, 315, 751 

Phenol (1 : 100) in the form of spray or 
gargle, 433 

Potassium permanganate solution (gr. 20 
to the pint [1.3 : 480.0]), applied as a 
swab or gargle, 430 

Salt solution (7 : 1000), as a spray in nasal 
diphtheria, 751 

Schick test, 758 

Tincture of the chloride of iron, 757 

Tonics, such as quinine, strychnine and, 
the chloride of iron, as supportive meas- 
ures, 757 

Toxin antitoxin as a preventive, 754 

DROPSY, 757 

Acet-theocin-sodium, 513 

Acupuncture, less favorable than incisions, 
only to be resorted to after other reme- 
dies fail, 537 

Adonidin, useful in cardiac dropsy, 77 

Apocynum, in cardiac or renal dropsy of 
the subacute or chronic type, 114 

Caffeine, in cardiac or renal dropsy, 761; 
in torpidity of kidneys, 168 

Calomel and digitalis, in renal and cardiac 
types, 377, 761 

Colocynth, compound extract of, gr. 5 to 
15 (0.3-1.0), 245, 759 

Copaiba, of service in slow renal types, 248 

Digitalis, m 5 to 15 (0.3-1.0), with caf- 
feine, gr. 2 (0.12), thrice daily, in renal 
torpidity due to heart trouble, 761 

Diuretin useful in all conditions, except in 
the presence of acute nephritis, 486 

Elaterium, especially useful in renal dropsy, 
268, 759 



Jalap, compound powder of, gr. 20 to 30 

(1.3-2.0), with potassium bitartrate, gr. 

15 (1.0), added, especially serviceable in 

renal dropsy, 344, 759 
] Magnesium sulphate, in concentrated solu- 
tion, before breakfast, 360, 760 
Milk diet, very useful, 760 
Paracentesis abdominis, very useful in 

ascites, 761 
I Pilocarpine, useful in localized and renal 

dropsy, contraindicated in cardiac types, 

443 
Pituitrin, 1U 15 (1.0) twice a day, is often 

efficient in cardiac dropsy, 761 
Potassium bitartrate with gin, in dropsy 

due to chronic nephritis, 454 
Potassium iodide, of value in some cases, 

but must be given cautiously if renal 

disease is present, 762 
Scoparius, infusion, may be used, 480 
Senega, rarely of value, 482 
Squill with digitalis, prescription for, 492, 

761 
Strophanthus, in cardiac dropsy, 497 
Sugar of milk, useful as a diuretic, 498 
Tapping in ascites, the best method, 761 

DYSENTERY, 748 

Antidysenteric serum in bacillary dysen- 
tery, 551, 748 

Arsenic, 123 

Arsphenamine recommended by some in 
amebic dysentery 749 

Bichloride of mercury, gr. ^ G (0.0003), if 
passages are slimy and bloody, 371, 749; 
injections (1 : 5000), followed by solu- 
tion (1 : 30,000) to prevent toxic effect 
by absorption, 374, 749 

Bismuth subcarbonate, in full doses, to 
control excessive purging, 749 

Boric acid, 3J to Oj (4.0 ; 480.0), or phenol- 
sulphonate of zinc, gr. 15 to 1 quart (1.0 : 
960.0) , very useful as rectal injection, 749 

Calomel, in purgative dose, contraindi- 
cated if weakness exists, 374, 376, 748 

Continuous irrigation with two-way tube, 
of great value, 749 

Copaiba, 248 

Copper sulphate, gr. 2 to the pint (0.12 : 
480.0), for irrigation of the colon, 249 

Creolin enemata, 251 

Emetine hydrochloride, gr. \ to f (0.03- 
0.04), in 30 minims of normal salt solu- 
tion, an efficient substitute for ipecac, 
334, 335, 748, 749 

Ergot, useful in bloody stools, 271 

Hamamelis, injections, if much blood is 
present, 749 

Ipecac, best remedy in acute dysentery, 
and is useful to prevent abscess if used 
early in amebic dysentery and hepatitis 
334 

Irrigation of colon, 586, 749 

Lead acetate, with opium and camphor, 
prescription for, 352 

Nitrohydrochloric acid, if due to defective 
action of secretory glands, 398 

Prescription for enema, 749 

Quinine injections, useful in amebic dysen- 
tery, 226, 749 

Silver nitrate, rectal injections (gr. 10 to 
20 to the pint [0.6-1.3 : 480.0]), if ulcers 
are chronic; followed by salt solution if 
action is too severe, 391, 750 



1006 



INDEX OF DISEASES AND REMEDIES 



Sulphate of magnesium, 361, 748, 749 
Taraxacum, in dyspepsia due to hepatic 
torpor, 510 

DYSMENORRHEA, 762 

Amyl nitrite, often relieves, 101 
Antipyrine or acetanilide, in neuralgic at- 
tacks, in other cases of doubtful value, 

111, 763 
Belladonna, suppository, gr. \ (0.03) of 

extract; tincture, internally, useful to 

relax spasm, 148 
Benzyl benzoate in spasmodic type, 151 
Camphor with acetanilide, in pill, useful in 

nervous cases, 177 
Cannabis and gelsemium, often of service, 

182, 763 
Corpus luteum useful in some cases, 250 
Epsom salt, if constipation is present, 762 
Ether or chloroform, 763 
Gelsemium, in spasmodic forms, 296, 763 
Hot sitz-bath, followed by turpentine 

stupe, and Dover's powder, gr. 10 (0.6), 

often relieves, 590, 762 
Hyoscyamus, extract, gr. 1, in suppository, 

if pain is persistent, 762 
Iron, strychnine, and quinine as tonics, 

with rest and horseback riding for 

anemic and run-down patients, 763 
Opium, to relieve spasm and pain, 415, 762 
Potassium bromide, 160 
Water, cold and hot, alternately dashed 

over loins in atonic cases, 763 

DYSPEPSIA. (See Indigestion.) 

Ammonium chloride, in painful dyspepsia 
due to hyperacidity, 99 

Arsenic, useful in atonic types associated 
with chronic diarrhea, 123 

Benzo-naphthol, in fermentative dyspep- 
sia, 152 

Bismuth, when due to acid fermentation, 
153, 154 

Bismuth subgallate, in fermentative dys- 
pepsia, 153 

Bryonia when due to gastric and intestinal 
atony, 165 

Diastase, with capsicum, in atonic dys- 
pepsia, 256 

Gentian, 296 

Hydrastis, as an antiseptic and curative 
agent in chronic types, 310 

Hydrochloric acid, if gastric secretion is 
deficient, 312 

Lavage, in fermentative dyspepsia, 616 

Nitric acid with bitter tonics, often relieves 
internal types, 394 

Permanganate of potassium, 430 

Quassia, useful if not due to gastritis, 461 

Serpentaria, as a tonic in atonic types, 483 

Strontium bromide, in painful dyspepsia, 
495 

Terebene, useful as an antiseptic in fer- 
mentative dyspepsia, 511 

DYSPNEA, 763 

Ammonium carbonate, as a respiratory 
and cardiac stimulant, 764 

Arsenic, continuously employed, useful in 
emphysema and chronic pulmonary in- 
flammation, 764 

Dry cupping over back, when due to car- 
diac or pulmonary trouble, 764 



Heroin said to be of value in uremic dysp- 
nea, 305 

Hyoscine, contraindicated, 764 

Morphine, gr. f to J (0.008-0.015) night 
and morning, often cures when due to 
nervous or cardiac disorders, 417, 764 

Opium, if due to nervous disorders, 764 

Strychnine, in idiopathic types and when 
due to bronchorrhea in old people, 406, 
764 

Thoracentesis if there is pleural effusion, 
764 

EAR (DISEASES OF). 

Bismuth subgallate, useful in purulent 
otitis media, 153 

Glycerin, useful to soften impacted ceru- 
men, 299 

Potassium permanganate, solution, useful 
in purulent otitis media, 430 

Scarlet red to aid healing in perforation of 
tympanic membrane, 479 

EARACHE, 764 

Cardiac sedatives, 764 

Chloroform, on swab, behind and in front 
of ear in otalgia, 766 

Cocaine, m 1 to 3 (0.06-0.2) of a 4 per cent, 
solution of adrenalin chloride (1 : 5000) 
solution, dropped into nostril, followed 
by spray if mucous membrane is en- 
gorged, 765 

Heat dry, applied to head on affected side, 
764 

Inflation of Eustachian tube with Politzer's 
air-bag, 765 

Irrigation with normal salt solution hot as 
can be borne, gives great relief, 765 

Leeching behind ear, to relieve pain, 764 

Menthol and albolene spray, following 
cocaine, 765 

Poultices, oil and laudanum, contraindi- 
cated, 764 

Puncture of tympanum, if it bulge, fol- 
lowed by careful cleansing and insuffla- 
tion of boric acid, 765 

Tincture of belladonna and of opium 
dropped into the ear, 765 

ECLAMPSIA, 912 

Amyl nitrite, dangerous, 101 

Anesthetics of little use, 914 

Croton oil, 2 minims (0.1), mixed with 
sweet oil, placed on tongue, 913 

Elaterium, gr. \ (0.015), rubbed up with 
butter, or compound jalap powder and 
calomel, may be substituted for croton 
oil, 914 

Extraction of child rapidly as possible, if 
attack comes on during labor, 914 

Hot-air bath, hot pack, or hot tub bath to 
induce sweating, 913 

Ice-bag to head while in warm pack, 913 

Lumbar puncture, 914 

Morphine, veratrum, and amyl nitrite may 
be held in reserve, to be used if neces- 
sary, 914 

Parathyroid gland, 426, 914 

Pilocarpine contraindicated, 914 

Sodium bicarbonate, Bj-Oij, by Murphy 
drip, to combat acidosis, 913 

Thyroid gland, full doses, for early symp- 
toms of eclampsia, 517 



INDEX OF DISEASES AND REMEDIES 



1007 



Venesection, hot wet pack, and croton oil, 
TR 2 (0.12), with sweet oil on tongue to 
eliminate poison, 645, 913 

Veratrum in full doses, 531, 914 

ECZEMA, 766 

Ammoniated mercury in chronic dry form, 
371 

Arsenic, only when skin is very dry, 122, 
768 

Bismuth subgallate in weeping eczema, 153 

Black wash of value in, 375, 766 

Calamine in moist eczema, 534 

Calomel ointment, 378 

Cantharis, internally, in small doses, 184 

Dermatol, in weeping eczema, 153 

Green soap, 485, 767 

Hygienic measures and diet, 766, 768 

Ichthyol ointment, highlv recommended, 
319 

Internal treatment, 768 

Iodoform ointment, prescription for, 331 

Iron, syrup of iodide, in young children 
with anemia and debility, 341 

Kaolin as a dusting-powder, 345 

Lead, dilute solution of subacetate, a use- 
ful lotion, 353 

Liquor carbonis detergens, in acute cases, 
767 

McCall Anderson's ointment, 766 

Methyl blue in eczema of the eyelids, 383 

Ointments, prescriptions for, 333, 767, 768 

Phenol ointment (minims 10 [0.6] to cerate 
1 ounce [30.0]), to prevent itching, 434, 
767 

Poultices, or olive oil with phenol (TO. 1 to 2 
to the ounce [0.05-0.1 : 30.0]), followed 
by soap and water, necessary in some 
cases to soften scales, before use of 
ointments, 767 

Prescription foriodol, as an ointment, about 
nose and lip, 332 

Resorcinol ointment (gr. 2 to 30 to the 
ounce [0.12-2.0 : 30.0]), locally applied 
in subacute types; in chronic form, oint- 
ment (gr. 2 to 10 to the ounce [0.12-0.6 : 
30.0]), solution, gr. x to xv (0.6-1.0) to 
f§j (30.0), in itching of erythematous 
form, 463, 767, 768 

Salicylic acid ointment (gr. 30 to 60 [2.0- 
4.0), to lard 1 ounce [30.0]), in chronic or 
weeping types, 472, 768 

Starch poultice, in crusty eczema, 493 

Tar ointment, in chronic forms, 510, 768 

Unna's dressing, 535 

Zinc carbonate, as a protective powder in 
weeping eczema, 534 • 

Zinc oxide, as a dusting-powder or oint- 
ment in early stages, applied directly 
or on lint, generallv preceded by black 
wash, 535, 766 

EMISSIONS, 768 

Bromide of sodium or potassium gr. 20 
(1.3) at bedtime, valuable in spinal ir- 
ritability, 160, 769 

Chloral, gr. 20 (1.3) at bedtime, 769 

Cold sponging of perineum and scrotum, 
563, 769 

Gold and sodium chloride in nocturnal 
emissions, 300 

Hygienic measures, 769 

Hvoscine, gr. T foj (0.0006;. of groat value, 
318, 769 



Monobromated camphor, very useful in 

spermatorrhea, 179 
Potassium citrate, gr. 20 (1.3), thrice daily 

to render urine non-irritating, 769 
Strychnine and arsenic, in full dose, of 

great service in genital atony, 769 
Warm bath before retiring, often useful, 

769 

EMPHYSEMA OF LUNGS. 

Climatic treatment, 624 
Cod-liver oil, useful, 240 
Euphorbia pilulifera, | to 1 dram (2.0- 

4.0) of the fluidextract, 290 
Iodide of potassium, 323 
Physostigma, aids in expelling mucus, 441 
Strychnine, 406 

EMPYEMA. 

Bismuth subcarbonate with petrolatum, 
30 per cent., by injection, 154 

Dakin's fluid, 894 

Drainage in, 893 

Iodine, gr. 6 (0.4) ; potassium iodide, gr. 6 
(0.4); water, 1 pint (500.0), as an irri- 
gating fluid, used daily, 328 

Pulmonary exercise to aid drainage, 604 

ENDOCARDITIS, 770 

Aconite, tincture of, 1U 3 (0.2) hourly, in 
early stages of acute sthenic types, 770 

Antistreptococcic serum in ulcerative endo- 
carditis, 554 

Blisters on precordium, to prevent endo- 
cardial complications, 770 

Ice-bag over precordium, 562, 770 

Iron, tincture of chloride, associated with 
supportive treatment, in purulent types, 
770 

Veratrum, used for same purposes as 
aconite, 770 



ENTERIC FEVER. (See Typhoid 
Fever.) 

ENTERITIS. (See Dysentery and 
Diarrhea.) 

EPIDIDYMITIS; 802 

Guaiacol ointment, 5 per cent., to relieve 
pain, 802 

Guaiacol used locally, highly recom- 
mended, 303 

Heat, moisture, and pressure, in later 
stages, to relieve induration, 803 

Iodide of potassium, gr. 3 to 5 (0.2-0.3) 
thrice daily, to remove induration, 803 

Iodine, painted over scrotum, said to be 
beneficial, 581, 803 

Leeches on the perineum, 619 

Magnesium sulphate solution to relieve 
pain, 361, 802 

Mercury and belladonna ointments, equal 
parts, or iodine, gr. 4 (0.25), with lanolin 
ounce 1 (30.0). locally applied, to relieve 
induration, 803 

Punctures, useful to relieve tension and 
alleviate pain, 802 

Rest in bed, elevation of pelvis and tes- 
ticles, cessation of local gonorrheal 
treatment, and administering treatment 
for acute inflammation, 802 



1008 



INDEX OF DISEASES AND REMEDIES 



Silver nitrate solution, painted over scro- 
tum, in early stage, may relieve, 392, 581 

Strapping and suspending testicle, to re- 
duce inflammation, 581, 802 

EPILEPSY, 770 

Acetanilide, 69,777 

Adonis vernalis with bromides have been 
found useful, 76, 774 

Amyl nitrite, inhalations, when aura is 
perceived and also in status epilepticus 
to relax spasm, 101, 775 

Anesthetics contraindicated in all cases 
except status epilepticus, when chloro- 
form may be used to control attack, 776 

Antifebrin and antipyrine, especially use- 
ful in some cases, 111, 777 

Belladonna, with bromides, recommended, 
774 

Bleeding for the status epilepticus, 776 

Borax may be used, 155, 777 

Bromide of ammonium, may be used with 
other drugs, 97, 774 

Bromide of calcium, 163 

Bromide of sodium, not so apt to disorder 
stomach, 163, 771 

Bromide of sodium, the most reliable in 
ascending dose, 159, 771 

Chloral, alone or with bromides, well 
diluted after meals, used with care, 195, 
776 

Diet, 777 

Digitalis, with bromides, useful in some 
cases, 774 

Duboisine, especially in psychic forms, 268 

Hydrobromic acid, liable to derange diges- 
tion, 163, 774 

Iodide of potassium useless _ except in 
syphilitics, 776 

Luminal in small dose at night, 357, 771 

Mercury, associated with potassium iodide 
when due to gumma, 776 

Mixed treatment, 774 

Monobromated camphor, 179 

Nitroglycerin, useful in some cases of 
petit mal, 396, 775 

Opium with gelsemium, only to be used 
when other remedies fail; also a pro- 
longed course of, in ascending doses, 
useful in old cases, 774 

Potassium or sodium nitrite, used to 
supplement amyl nitrite, 395, 776 

Silver nitrate may be tried when other 
remedies fail, 392, 775 

Solanum carolinense, fluidextract of, 2 to 
15 minims (0.12-1.0), thrice daily in the 
epilepsy of childhood, 491, 777 

Strontium bromide, 773 

Tartar emetic ointment, as a counter- 
irritant at back of neck, 106 

EPISCLERITIS, 778 

Antiseptic collyria, 778 

Atropine locally, 778 

Dionin, 5 per cent., to relieve pain, 778 

Eserine or pilocarpine if there is a rise of 

intra-ocular tension, 778 
Hot compresses, 778 
Iodide of potassium and salicylates, 778 
Tuberculin when tuberculous in origin, 778 
Yellow oxide of mercury ointment, gr. j— 

3j, for massage of eyeball, 778 



EPISTAXIS, 778 

Acetanilide, used locally, has been recom- 
mended, 69 

Acetic acid, locally applied to arrest, 70 

Aconite or veratrum, tincture, 1U 6 to 12 
(0.4-0.8), in sthenic cases, followed in 
thirty minutes by smaller doses, if 
necessary, 75, 778 

Adrenalin, locally, 504, 779 

Bacon fat, inserted as a plug in nostril, 
may arrest, 779 

Compound tincture of benzoin on cotton to 
place in nasal chamber to control, 779 

Compression of facial artery may be neces- 
sary, 779 

Cotarnine, locally, 251 

Ergot, turpentine, hamamelis, or oil of 
erigeron, internally in slow oozing, 271, 
272, 778 

Hot foot-bath, or hot- or cold-water bags 
applied to dorsal vertebrae, may arrest. 
779 

Ice applied to nose, may arrest. 779 

Ipecac, in nauseating doses, recommended. 
778 

Monsel's solution, in spray (1 5 to 1 
ounce [0.3 : 30.0]), only to be tried 
when other remedies fail: very disagree- 
able, 342, 779 

Oil of erigeron. 272, 778 

Plugging anterior and posterior nares, if 
necessary, with cotton or lint soaked in 
vinegar. 779 

Vinegar or lemon-juice injected into nostril. 
779 

EPITHELIOMA. 

Acid nitrate of mercury, applied to part 

with glass rod, 380 
Arsenic trioxide and gum acacia (of each 

1 ounce [30.0] to water 5 fluidrams 

[20.01). locally applied. 124 
Carbon-dioxide snow, 560 
Resorcinol. in epithelioma of the fane. 463 

ERYSIPELAS, 779 

Alcoholic stimulants, if patient passes into 
typhoid state, 780 

Aluminum acetate useful. 92 

Antistreptococcic serum, 554 

Bitters and iron, during convalescence, as 
tonics, 780 

Boric acid, as a lotion, 156 

Cold bathing to control excessive fever, 
780 

Ichthyol ointment and vaseline, half-and- 
half, locally applied, preceded by wash- 
ing with Castile soap, followed by 
bichloride solution (1 : 1000), 319, 780 

Iodine, tincture, painted around inflamed 
edges, to arrest, 327 

Iron, tincture of chloride, 1U 10 (0.6) every 
hour, well diluted, best internal treat- 
ment, 339, 780 

Magnesium sulphate solution excellent, 361 

Phylocogens, 628 

Pilocarpine, gr. | to i (0.008-0.01), hypo- 
dermically, contraindicated in debility; 
also injected around borders of inflam- 
mation in some cases, to arrest, 445 

Silver nitrate, solution (gr. 80 to \ ounce 
[5.3 : 16.0]), applied twice or thrice to 
arrest, 392, 780 






INDEX OF DISEASES AND REMEDIES 



1009 



White-lead paint, locally applied when 
ichthyol is not at hand. 780 

EXHAUSTION AND DEPRESSION. 780 

Stimulants. 781 

EXOPHTHALMIC GOITER. 781 

Barbital, 781 

Belladonna relieves some cases. 148 

Bromides, 781 

Cannabis acts as a nervous sedative. 181 

Diet. 781 

Lecithin as a tonic, 353 

Radium, 781 

Rest cure, 781 

Sparteine, 480 

Thvroidectin, 519 

X-rays for. 781 

EYE-STRAIN, 781 

Correct error of refraction, 782 
Gelsemium, in headache due to eye-strain, 
296 

FEET (SWOLLEN, TENDER, OR 
SWEATING), 782 



Arsenic trioxide, gr. 



to 



(0.001- 



0.0015), in swelling of old eprsons, 123, 

782 
Borax, stockings soaked in saturated solu- 
tion and dried, each day, when sweating 

is excessive, 783 
Carbonate of calcium, precipitated, locally 

applied to sweating feet, 170 
Cotton instead of of woolen stockings may 

aid cure, 783 
Formaldehyde, 783 
Hamamelis, distilled or fluidextract, dram 

% to 1 (2.0-4.0) of former, or m 10 to 20 

(0.6-1.3) of latter, 782 
Lead plaster and linseed oil, equal parts, 

applied on linen to feet, every third day, 

for sweating, 353 
Prescription for dusting-powder, 783 
Rest, absolute, of feet, may be necessarv in 

swollen feet, 782 
Salicylic acid and borax, equal parts, in | 

water and glycerin, best application to i 

sweating and tender feet, 783 

FELON. 

Bread-crumbs saturated with liquor plumbi 
subacetatis, as a poultice, to abort, 353 

Phenol locally to cause anesthesia in open- 
ing, 434 

Silver nitrate solution, applied early, to 
abort, 392 

FEVER, 783 

Acetanilide, 68 

Aconite, the best depressant for sthenic 
types in children, 75 

Alcohol, as a systemic support and stimu- ! 
lant in low fevers, 81 

Ammonia for sudden cardiac failure in, 94 

Antimonial powders as an antipyretic, 105 ! 

Antipyretics, useful in most sthenic fevers, 
often fail in thermic fever, 783, 784, 785 

Antipyrine, 110 

Brand's method, 570 

Camphor a diffusible stimulant in ady- 
namic fevers, 177 

64 



Capsicum as a stimulant in low fevers, 185 
Coca a supportive and stimulant in low 

fevers, 237 
Cold applications and baths, 566, 784, 785 
Cold packs and baths in asthenic types to 

be relied on first; if impracticable, then 

antipyretics, 784 
Guaiacol, useful in, 302 
Hydrochloric acid in adjuvant to digestion, 

312 
Musk, by rectal injections, valuable in low 

stages, 386 
Mustard hot-pack in eruptive fevers in 

children, 387 
Neutral, mixture useful as a febrifuge, 

especially in children, 456 
Phenacetin, 72 

FIBROIDS. 

Ergot, used as an expulsive and curative 
remedy, 271 

FLATULENCE. 

Aromatic powder, 230 

Asafcetida, 139 
] Beta-naphthol in gastric fermentation and 

flatulence, 151 
i Camphor, 177 
I Capsicum prevents formation of gas, 185 

Charcoal, 186 
' Chloroform, m 1 to 2 (0.06-0.12), or spirit 
, m 10 to 20 (0.6-1.3), will relieve, 213 
1 Cloves, a useful tonic and stimulant, 232 
[ Ginger, 297 

Hoffmann's anodyne, the best carminative 
282, 307 
! Pepper, 426 

Peppermint, 427 

Podophyllin with euonymin, leptandra, 
chirata, and creosote, 451 
! Potassium permanganate, 430 
! Turpentine, prescriptions for, 527 

FRECKLES AND CHLOASMA, 785 

Almonds, emulsion of, supposed to be of 

value, 88 
Boric acid, saturated solution, applied same 

as corrosive sublimate wash, 156, 785 
Corrosive sublimate (gr. 1 to 4 to the ounce 

[0.06-0.25 : 30.0]), applied night and 

morning until irritation appears, then 

stop for some days and again renew, 

785 
Lactic acid (gr. 10 to the dram [0.6 : 4.0]), 

applied same as corrosive sublimate, 

785 
Prescription for, 785, 786 
Prescription for chloasma of pregnancy, 535 



FURUNCLES. (See Boils.) 

GALACTORRHEA, 911 

Antipyrine, gr. 2| (0.15) thrice daily, said 

to decrease secretion, 911 
Belladonna, 147 
Caustic, introduced into uterus, successful 

in some cases by inducing menstrual 

flow, 911 
Chloral should be tried, 911 
Compression of gland with applications of 

belladonna ointment and potassium 

iodide internally, usually relieves, 911 



1010 



INDEX OF DISEASES AND REMEDIES 



Diet, 911 

Electricity, generally ineffective, 911 

Ergot, long continued, highly recom- 
mended, 911 

Malt, wineglassful at midday and evening 
meals, useful addition to diet; pyro- 
phosphate of iron, gr. 4 (0.25), in addi- 
tion, if anemia is present, 912 

Warm douches, 911 

GANGRENE. 

Bromine, as an escharotic in hospital gan- j 

grene, 164 
Nitric acid, to destroy tissue, 394 
Phenol or creosote, spray (TH. 5 to 15 to 
the ounce [0.3-1.3 : 30.0]), useful in pul- 
monary gangrene, 433 

GASTRALGIA. 

Acetanilide, 69 

Bismuth and phenol, after meals, to pre- 
vent pain, 154 

Bromide of strontium, a valuable remedy, 
495 

Cannabis, prescription for, 182 

Chloretone, gr. 5 to 10 (0.3-0.6), is useful, 
198 

Counterirritation and a vigorous revulsive, 
especially useful in hysteria, 581 

Hydrocyanic acid, useful in nervous types, 
313 

Menthol, 427 

Nitroglycerin, 396 

Potassium nitrite, gr. 4 to 5 (0.25-0.3), 395 

GASTRIC ATONY. 

Arsenic, prescription for, 123 

Gentian, 296 

Prescription for, in drunkards, 84 

GASTRIC CATARRH (ACUTE), 786 

Ammonium muriate, useful in subacute 
forms in children, prescription for, 99 

Bismuth hydroxide, 154 

Bismuth subnitrate, gr. 2 (10.2), and 
cerium oxalate, gr. 1 (0.06), every two 
hours, 786 

Diet, principal point in treatment, 786 

Effervescing draughts, useful in convales- 
cence, 786 

Flannel, to protect abdomen, 787 

Ice, to quench thirst, 786 

Iron, if anemia exists, 787 

Milk, with large percentage of lime-water, 
786 

Milk of magnesia, as a mild purge to dis- 
lodge fermenting mass, 786 

Salicylic acid, valuable in vomiting, 471 

Seidlitz powder, one-fourth of one powder 
every fifteen minutes, to settle stomach 
and remove fermenting mucus, 787 

Sodium bicarbonate with gentian, useful, 
786 

Spice poultice to relieve epigastric distress, 
581, 787 

GASTRIC CATARRH (CHRONIC), 787 

Apomorphine, as an emetic, to throw off 

mucus, 116 
Arsenic for the vomiting, in hand-fed 

babies, 123 
Bicarbonate of sodium for hyperacidity, 78 7 



Bismuth subnitrate, added to prescription, 
if hyperacidity exists, 787 

Carlsbad salt, Saratoga-Carlsbad water, or 
Seidlitz powder of great benefit, 787 

Cascara sagrada, if constipation exists, 787 

Charcoal, prescription for, 187 

Diet, such as koumyss, light broths, and 
matzoon, 787 

Hydrochloric acid, if due to atrophy of the 
gastric tubules, 312, 788 

Hyoscyamus useful with silver nitrate, 316, 
787 

Lavage, almost always to be used, 787 

Silver nitrate and hyoscyamus ,with coun- 
terirritation and regulated diet, 391, 787 

GASTRIC DILATATION, 788 

Beta-naphthol, if fermentation is marked, 
789 

Cold douches, 788 

Diet, 788 

Exercise, 788 

Faradization of gastric walls, 788 

Hydrochloric acid, to aid digestion, 312,788 

Lavage, 616, 788 

Physostigma useful, combined with nux 
vomica, 441 

Salicylic acid as an antiseptic when vomit- 
ing occurs and when the vomited matter 
contains sarcina?, 471 

Taka-diastase taken with meals, 788 

GASTRIC AND DUODENAL ULCER, 

789 

Adrenalin chloride solution, 3J (4.0), some- 
times, gives good results in relieving 
hematemesis, 791 

Arsenic, 123 

Bismuth and sodium bicarbonate, as an 
astringent and sedative, and to these 
may be added morphine, dionin or 
codeine for pain, 154, 790 

Carlsbad salt, magnesium sulphate, or 
sodium phosphate for relief of constipa- 
tion, 791 

Chloretone of A r alue to relieve pain, 198, 790 

Cocaine, gr. j (0.015), alone or combined 
with bismuth, to control vomiting, 791 

Cold compresses or an ice-bag applied to 
epigastrium in hematemesis, 791 

Counterirritation, continuous, over belly 
to relieve pain, 790 

Creosote or carbolic acid for vomiting, 791 

Diet and hygiene, 789, 790 

Dionin as a substitute for morphine, 267 

Hypodermoclysis, 789 

Lenhartz's treatment, 789 

Massage and electricity, 789 

Milk of magnesia, \ ounce, at bed- time to 
relieve distress of duodenal ulcer, 792 

Mineral oil to soothe duodenal ulcer and 
prevent intestinal stasis, 792 

Monsel's solution, cold compresses, or adre- 
nalin chloride, may be given to check 
hematemesis, 791 

Morphine for pain or collapse following 
perforation, 790 

Orthoform may relieve pain, 421 

Rectal alimentation, 789 

Resorcinol, useful in some cases, 463 

Rest for the patient and rest for the stom- 
ach essential, 789, 790 

Silver nitrate with hyoscyamus in pill, half 
to one hour before meals, 316, 391, 790 



IXDEX OF DISEASES AND REMEDIES 



1011 



Sodium bicarbonate, § dram, between 
meals, in duodenal ulcer to overcome 
gastric hyperacidity with pyloric spasm, 
792 

Sodium citrate, 488 

Spice plaster, useful as a continuous coun- 
terirritant, 790 

Stimulants, cardiac, guardedly adminis- 
tered, external heat and rubbing, in col- 
lapse, following hemorrhage or perfora- 
tion, 791 

GASTRITIS (ACUTE), 792 

Bismuth, as an astringent and sedative, 154 
Flaxseed tea, a useful demulcent, 291 
Mucilaginous drinks and albuminous sub- 
stances freely given, 792 
Oils, to prevent spread of inflammation, 792 
Opium, in fluid form, to relieve pain and 

irritation, 792 
Sodium citrate, 488 

Warm water, internally, or stomach-pump, 
to unload stomach at onset, 792 

GASTRO-ENTERITIS, 793 

Castor oil or magnesium sulphate, to sweep 
out poison, 793 

Morphine hypodermically, to allay pain, 
followed or preceded by mild, rapidly 
acting emetic, if irritating substance 
remains, 793 

Opium, with hot applications or plasters 
to belly, to control irritation and diar- 
rhea 793 

Predigested food, 793 

GASTRO-INTESTINAL CATARRH. 

Ammonium chloride, useful in subacute 

types in children, 99 
Carlsbad, Vichy, or other alkaline mineral 

water of purgative powers, often useful, 

623 
Diet for seven-year-old child, 654 
Garlic, as a poultice to belly almost equal 

to spice poultice, 87 
Gentian with bicarbonate of sodium useful 

in children, 296 
Hydrastis, especially useful if due to alco- 
holism, 310 
Ichthyol internally, 320 
Sanguinaria, of service if jaundice is 

present, 475 
Sodium bicarbonate, 10 to 20 grains, 487 
Subsalicylate of bismuth in the presence of 

fermentation or putrefaction, 155 
Tar, in 2-gr. (0.12) pills, 509 

GIDDINESS. 

Cod-liver oil with quinine, valuable in old 

age, 240 
Ergot and bromides useful, 271 

GLANDS (DISEASED). 

Cod-liver oil, in lymphatic enlargements, 
240 

Counterirritation, 579 

Ichthyol ointment, valuable as an inunc- 
tion in lymphatic enlargements, 319 

Iodine, the best remedy for enlargements, 
326 

Mercury ointment as an inunction in en- 
larged glands, 379 



Phenol (2 per cent, solution), injected into 
glands threatening suppuration, 434 

Potassium iodide for enlargements of the 
cervical glands, 323 

GLAUCOMA, 793 

Atropine, contraindicated, 794 

Dionin in 1 to 5 per cent, solution, 267, 794 

Eserine (gr. 1 to 2 to the ounce [0.06-0.12 : 
30.0]), or pilocarpine nitrate (gr. 2 to 4 
to the ounce [0.12-0.25 : 30.0]), dropped 
into eye if operation is delayed, 441, 794 

Hot compresses, leeches, and opiates to 
relieve pain, 794 

Iridectomv, the only curative treatment, 
i 794 

Pilocarpine in, 444, 794 

Sodium salicylate, full doses, internally, 
794 

GLEET. 

Bichloride of mercury, injection (gr. | to 
water 6 ounces [0.03 : 180.0]), every 
three or four hours, 374 

Cantharis, 184 

Sandalwood oil, 475 

Turpentine, internally, 527 

Uva ursi, 528 



GOITER. (See Bronchocele.) 

GONORRHEA (ACUTE), 794 

Aconite, 1U 6 (0.4) every two or three 
hours, if inflammationis high, 75, 798 

Almond emulsion, diminishes burning on 
urination, 88 

Argyrol, 1 to 10 per cent., as injection, 
117, 797 

Benzoic acid, with cannabis, useful in later 
stages, 150 

Bicarbonate of sodium or potassium citrate 
gr. 10 (0.6), after meals, increasing, if 
necessary, relieves ardor urinal, 798 

Cannabis often used in later stages instead 
of copaiba and cubebs, 182 

Cinnamon oil, by injection or spray, 230 

Cocaine, solution (4 per cent.), instilled 
into urethra before urination, diminishes 
ardor urinse, 798 

Copaiba and cubebs, useful in later stages, 
248, 255, 796 

Erigeron oil, occasionally used instead of 
copaiba and cubebs, 272 

Eucalyptus, valuable in subacute stages, 
289 

Hot bath, prolonged, before going to bed, 
798 

Hydrastis, one of the best remedies, locally 
and internally, in later stages; also as 
a vaginal wash for females, 310 

Lead acetate, injection, gr. 1 to 8 to the 
ounce (0.06-0.5 : 30.0), 352 

Lead-water and laudanum, or alcohol and 
water, applied on a cloth to penis, dur- 
ing inflammation, 798 

Mercurol, 363 

Mercury bichloride in females, 2 pints of 
solution (1 : 4000) thrice daily, to irri- 
gate vagina, 803 

Methylene blue, 385 

Nargol, argyrol, or protargol injections, 
1 to 10 per cent., 797, 799 



1012 



INDEX OF DISEASES AND REMEDIES 



Opium or belladonna, hypodermically or in 
suppository, to control pain in posterior 
urethritis, at same time discontinuing 
active treatment, and observing strict 
hygiene and diet, 799 

Permanganate of potassium solution (1 : 
6000), as an antiseptic, 797 

Prescription for administration of balsams, 
796 

Prescriptions for checking the discharge, 
797 

Protargol, 460, 795, 796, 799 

Quercus, injections, useful in females, 462 

Salol (phenyl salicylate), 474, 796 

Silver nitrate, injections (gr. \ to 3 ounces 
[0.03-90.0]), useful in subacute stage; in 
females, gr. 4 to 40 to the ounce (0.25- 
2.6 : 30.0), painted over vagina, followed 
by astringent cotton tampon, 392, 800, 
803 

Silvol, 10 to 20 per cent, solution, by injec- 
tion, three or four times a day, may 
be used, 485 

Urinating with penis in hot water, to re- 
lieve ardor urinse, 798 

Vaccines in, 643 

Warm baths, lasting one-half to two hours, 
useful in early stage, 797, 798 

Zinc acetate, injection, gr. 1 to 20 to the 
ounce (0.06-1.3 : 30.0) of rose-water, 533 

Zinc chloride, injection, gr. 1 to 2 to the 
ounce (0.06-0.12 : 30.0), occasionally 
used in second stage, 534 

Zinc sulphate, weak solution, as an astring- 
gent, 536 

GONORRHEA (CHRONIC), 799 

Bichloride of mercury useful in, 374 

Copaiba useful, 248 

Copper sulphate or silver nitrate, solution, 
as an application, after dilatation, to 
focus of inflammation, 800 

Dilatation, if stricture exists, 800 

Irrigations daily with silvol, argyrol, or 
protargol (1 : 3000-1 : 500), silver nitrate 
(1: 5000), mercurol (1 : 2000), or potas- 
sium permanganate (1 : 2000-1 : 500), 
800 

Prescriptions for, 800 

Pressure and use of cold, often valuable, 
800 

Sandalwood oil, to stimulate depraved 
mucous membrane, 475 

Silver nitrate, solution, if discharge per- 
sists after dilatation; also in posterior 
urethritis, 800 

Unna's treatment with coated sounds, pre- 
scription for, 800 

Uva ursi, 528 

Vaccines, 804 

GOUT, 804 

Antipyrine said to have a specific effect, 
111 

Barbital or barbital sodium for insomia, 
805 

Chloral, in insomnia, 805 

Chloroform liniment, applied over affected 
part, 213 

Cinchophen or atophan useful, 141, 230 

Cod-liver oil, 240, 806 

Colchicum, wine of seed, Tit 40 (2.6), in- 
creasing by 1U 2 (0.12), every four hours 
until symptoms are relieved or appear 
toxic, in acute types, 242, 805 



j Collodion, not more than one or two coats; 
also useful with iodine, 244, 805 

Diet, 805 

Fowler's solution, 1U 3 (0.2), in water, a 
standard remedy in subacute and 
chronic types, 806 
' Gentian, 296 
j Guaiac recommended as preventive, 301 

Hot air, of little value, 599 

Hot baths useful, 623 
! Iodide of iron, syrup of, and cod-liver oil 
if anemia is present, 806 

Iodide of potassium, to relieve night pains; 
also with colchicum, in chronic gout, 805 

Iodine, ointment or tincture, locally ap- 
plied to chronic gouty joints, 806 

Leeches or venesection, contraindicated, 
805 

Lithium carbonate or citrate (gr. 5 to 10 
to the ounce [0.3-0.6 : 30.0]), locally 
applied, to dissolve deposit around 
joints, 356, 806 

Morphine, hypodermically, to relieve 
acute pain, 804 

Neocinchophen useful, 390 

Potassium permanganate, 430 

Saccharin, used instead of sugar, 467 

Salicylates in large dose, mav be useful in, 
470 

Sodium bicarbonate and linseed oil (1 : 9), 
locally applied to joints, 805 

Stimulants, ether Ivypodermically, opium 
except in brain or kidney disturbances; 
diuretic and alkaline drinks and counter- 
irritation, to retrocedent gout, 806 

Strontium bromide, the best remedy for 
insomnia, 805 

Water, distilled or medicinal, in large 
amounts, 804, 806 

GRANULAR LIDS. 

(See Conjunctivitis, Granular.) 
GRAVES' DISEASE. 

(See Exophthalmic Goiter.) 

GRIPING. 

Allspice or ginger, to prevent griping of 

purgatives, 447 
Belladonna useful, 147 
Oil of peppermint, 427 

GROWTHS (PATHOLOGICAL). 

Acid nitrate of mercury, 380 

Caustic potash or soda, occasionally used 

to destroy, 457 
Chromium trioxide, as a caustic to destroy 

growths on skin or mucous membranes, 

218 
Hydrogen peroxide solution useful for 

cleansing malignant growths, 315 
Lime as an escharotic on hairy growths, 

174 
Methvlene-blue, 384 
Nitric acid, 394 
Pyoktanin, 383 
Sodium ethylate to remove hairy growths, 

489 
Thiosinamine has been used with some 

success in malignant growths, 514 

GUMS (DISEASES OF). 

Burnt alum, useful if applied to swollen 
gums, 91 



INDEX OF DISEASES AND REMEDIES 



1013 



Garabir, as a mouth-wash, for spongy 
gums, 294 

Iodine, solution (gr. 1 to the ounce [0.06 : 
30.0]), locally applied, followed by rins- 
ing mouth, when gums are retracted, 328 

Myrrh, tincture, locally applied, to spongy 
or tender gums, 388 

Thymol, prescription for, in tenderness 
after mercurialization, 515 

HAY FEVER. 

Adrenalin, locally, to relieve engorgement, 

504 
Arsenic, 123 
Cocaine with bismuth and morphine, as a 

snuff, 235 
Pituitrin, diluted from three to ten times 

with normal salt solution, locally in place 

of adrenalin, 450 
Pollen proteins, 630 
Resorcinol, solution 2 per cent., in spray, 

463 
Terpine hydrate, in full dose, 512 

HEADACHE, 806 

Acetanilide, 69 

Aspirin, in 10-gr. (0.6) doses, is very useful, 
808 

Belladonna, valuable in young people, 148 

Bleeding, 807 

Caffeine, with antipyrine or sodium bro- 
mide, in nervous headache, 168, 808 

Calcium chloride or lactate, in persistent 
dull headache with decreased coagula- 
tion of blood, 172 

Camphor, with acetanilide or antipyrine, in 
nervous headache, 177 

Cannabis, when at menopause or due to 
retinal asthenopia, 181 

Capsicum plaster to nape of neck, 185 

Castor oil, daily, in neuralgic headache, 
190 

Cimicifuga, if due to eye-strain, 219 

Colchicum, in gouty headache, 808 

Counterirritation, 581 

Croton chloral, if due to eye-strain or asso- 
ciated with sick stomach, 254 

Cup, to nape of neck, in congestion, 807 

Ergot, if due to congestion, 271, 807 

Gelsemium, if due to nervous troubles or 
eye-strain, 296 

Horseback exercise and sleep very useful 
in obtaining relief from nervous head- 
ache, 808 

Hydrobromic acid, if due to eye-strain in 
nervous women, 163 

Ice-bag, applied to head, or leeches behind 
ears, in severe cases, 807 

Liquor magnesii citratis, in sick headache, 
359 

Magnesium carbonate, gr. 5 to 60 (0.3- 
4.0; , in sick headache due to gastric 
acidity, 359 

Mercury, when due to syphilis, 368 

Mustard foot-bath and plaster to nape of 
neck, in congestion, 387, 807 

Nux vomica, 1U 1 (0.06), every five or ten 
minutes till 10 minims (0.6) are taken, 
in sick headache, 406 

Phenacetin, if due to eye-strain or neural- 
gia, 72 

Potassium bromide, 159, 808 

Prescriptions for, 807, 808, 809 



Salicylic acid or iodide or acetate of potas- 
sium, if due to gout, 808 

Sodium bicarbonate, as an antacid in sick 
headache, 487 

Strychnine or nux vomica, in sick head- 
aches or if due to eye-strain, 406, 807 

HEART DISEASE, 809 

Aconite or veratrum, often us_eful in palpi- 
tation and hypertrophy, 75, 819, 820 
i Adonidin, often of service when digitalis 
fails, 77, 816 

Adrenalin intravenously in cardiac and 
vasomotor failure, 504 

Alcohol in heart failure due to shock or to 
poisons, 81 . 

Ammonia and ether, followed by digitalis 
and alcohol, in heart failure, 94, 817 

Amyl nitrite, in single whiffs, often relieves 

cardiac failure, 102 
, Baths, Nauheim, formula for, 820, 821, 822 
' Belladonna when arrhythmia is present, 
818, in palpitation, 146 

Cactus grandiflora, useful in valvular dis- 
ease with incompetency, cardiac weak- 
ness, and palpitation, 166 

Caffeine, very useful, 168, 818 

Camphor, in palpitation, 177 

Cimicifuga, as a tonic in fatty and irritable 
heart when digitalis fails, 219 

Citrate or bitartrate of potassium with 
digitalis when secretion of urine is 
scanty, 818 

Climatic treatment, 627 

Convallaria majalis, in cardiac arrhythmia 
247 

Diet, exercise, and hygiene, 818, 819 

Digestive remedies, in palpitation due to 
indigestion, 818 

Digitalis, to be tried in all heart troubles, 
except in simple or compensatory hyper- 
trophy, 261, 810, 816, 818 

Electric cabinet bath or hot-air treatment, 
817 . 

' Hoffmann's anodyne, very useful in palpi- 
tation due to indigestion or tobacco, 307 

Hydragogue, cathartics for the dropsy and 
portal engorgement, 817 

Iodides to relieve tension in fatty heart, 818 

Iron, arsenic, and simple bitters, for asso- 
ciated debility and anosmia, 817 

Iron, in palpitation due to anemia, 818 

Nitroglycerin, when arterial tension is high, 
397, 817, 820 

Nux vomica, as a stimulant, 818, 820 

Opium, if dyspnea prevents sleep, 418 

Pituitrin useful in tachycardia and myo- 
cardial feebleness, 450, 817 

Potassium bitartrate or citrate with digi- 
talis for scanty secretion of urine, 818 

Quinidine in auricular fibrillation, 226 

Rest cure valuable, 632, 810 

Rest in bed essential when aconite is used, 
820 

Sparteine, in arrhythmia for palpitation, 
also as a substitute for digitalis, if it 
fails, 480, 818 

Strophanthin or strophanthone, intraven- 
ously, in presence of circulatory failure, 
814, 816, 817 

Strophanthus, if digitalis fails, 497, 814. 
816, 817 

Suprarenal gland, in heart failure due to 



lack of vascular tone, 504 



1014 



INDEX OF DISEASES AND REMEDIES 



Venesection followed by digitalis for over- Tannic acid, Monsel's solution, or alum 



distended right ventricle, 817 
Veratrum, 530 

HEMATEMESIS, 826 

Adrenalin, 1 dram of a 1 : 1000 solution, 

826 
Bandages to extremities and external heat ! 

if faintness ensues, 826 
Hamamelis, internally, 304 
Morphine to produce general and gastric \ 

rest, and to aid formation of a clot, 825 
Monsel's salt, gr. 2 to 3 (0.12-0.2), in pill, 

342 

HEMATURIA, 827 

Adrenalin chloride (1 : 5000) as injection, 

827 
Alum, gr. 2 to 3 (0.12-0.2), to water 1 

ounce (30.0), injected into bladder, if i 

alarming, 827 
Astringent injections, should be used only 

when bleeding is alarming, 8 §7 
Cups over kidneys, 828 
Gallic acid, gr. 20 (1.3), very valuable, 293 
Hamamelis, injected daily into bladder or 

used internally, 304 
Morphine and atropine hypodermically 

and cups over kidneys in, 828 
Quinine, usually harmful, unless due to 

malaria, 827 
Rhus aromatica, 465 
Sodium thiosulphate, 10 to 30 grains (0.6- 

2.0) every four hours, in malarial hema- 
turia, 490, 827 
Turpentine, 527, 827 

HEMOPHILIA. 

Calcium chloride, 171 

Calcium lactate, 171 

Hemostatic serum, 599 

Magnesium carbonate may be used, 359 

Transfusion, 633 

HEMOPTYSIS, 824 

Acetanilide has been recommended, 69 
Aconite, to prevent pneumonia following 

contraindicated in exhaustion, 825 
Alum solution (gr. 20 to the ounce [1.3 : 

30J), in fine spray, 91 
Amyl nitrite, used successfully by bleeding 

a man into his own bloodvessels, 101, 

825 
Artificial pneumothorax in, 944, 946 
Chloral and bromides, to allay nervous 

excitement, 825 
Chloroform, by inhalation with care, if 

nitrites are not available, 825 
Esmarch bandages to limbs when aconite 

cannot be used, because of exsanguina- 

tion, 825 
Gallic acid, gr. 20 to the ounce (1.3 : 30.0) 

of water, when ergot is not at hand, 293 
Hamamelis, 304 
Ice or ice-cold compress to the scrotum or 

vulva in, 825 
Ice or dry cup over bleeding spot, 825 
Ipecac, in small doses, very effective, 335 
Morphine, hypodermically, to allay ner- 
vousness and cough, 416, 825 
Nitroglycerin, gr. ^ to s\ (0.0006- 

0.0015), 397, 825 



used in spray, as styptics, prescriptions 
for, 342, 508, 825 

HEMORRHAGE, 823 

Acacia solutions, 615 

Adrenalin in hemorrhage from small 
vessels, 504 

Alum, a useful styptic, applied to bleeding 
vessel, 91 

Antipyrine, 112 

Arnica, 117 

Blood-serum, 1 ounce (30.0) daily by hypo- 
dermic injection, should be resorted to, 
823 

Cinnamon, in uterine hemorrhage, 230 

Compress, soaked in antiseptic liquid or 
filled with antiseptic powder, preferable 
to styptics, 823 

Ergot in postpartum hemorrhage, 270 

Gelatin, locally and hypodermically, to aid 
in the coagulation of blood, 823 

Hamamelis, useful for uterine oozing and 
bleeding from the bladder, 304 

Hemostatic serum in persistent hemor- 
rhage from small vessels, 599 

Hypodermoclysis, 601, 823 

Intravenous saline injections, 614 

Ligation, preferable to styptics, when 
applicable, 823 

Monsel's solution, 342 

Oil of erigeron, 272 

Packing of astringents, if bleeding-point 
cannot be reached by compression or 
for ligation, 823 

Sulphate of sodium by the mouth or intra- 
venously; useless hypodermically, 490 

Tannic acid, 508 

Transfusion, 633, 823 

HEMORRHAGE (INTESTINAL), 826 

(See also Hemorrhage.) 

Adrenalin chloride, 826 

Coagulose and horse serum or human 
serum, 826 

Chloride of calcium, 171 

Enemas, styptic, for hemorrhage from 
rectum or colon; adrenalin chloride, 2 
drams of 1 : 1000 solution in \ pint of 
normal salt solution; alum (gr. 10 to the 
ounce [0.6 : 30.0]), copper (gr. 5 to the 
ounce [0.3 : 30.0]), Monsel's solution (dr. 
\ to 2 ounces [2.0 : 60.0]), Monsel's salt 
(gr. 10 to the ounce [0.6 : 30.0], or dram 
\ [2.0] to water 2 ounces 1.60.0]), chlorate 
of potassium (gr. 10 to 25 to the ounce 
[0.6-1.6 : 30.0]), tannic acid (gr. 20 to 
the ounce [1.3 : 30.0]) of glycerin and 
water, 826 

Ergot, 270 

Ice-bag to the belly if patient is not in col- 
lapse, 826 

Ice-water injections in bloody purging of 
dysentery, 826 

Monsel's solution not advisable, 342 

Morphine hypodermically, 826 

Transfusion, 826 

Turpentine, in capsule or emulsion, when 
bleeding is not active, 527 

HEMORRHOIDS, 828 

Aloes, 89 

Antipyrine with cocaine in suppository to 
check bleeding and relieve pain, 112 



INDEX OF DISEASES AND REMEDIES 



1015 



Cocaine and iodoform ointment, prescrip- 
tion for, 829 

Cold-water injections in the morning re- 
lieve congestion and cause easy evacua- 
tion, 829 

Ergot, sometimes useful in bleeding piles, 
271 

Gallic acid and ointment of stramonium 
equal parts, 293 

Gallic acid and opium suppository, pre- 
scription fv>r, 828 

Hamamelis, internally or as a lotion or 
injection, 304, 829 

Hot compress wet with adrenalin chloride, 
1: 2000, 829 

Hygiene and general rules, 828, 829 

Iodoform suppository, if ulceration is 
present, 332 

Lead-water and laudanum lotion, after 
acute stage is passed, 829 

Linseed oil, 291 

Nitric acid, lightly touched to one or two 
points; as a lotion, J to 1 dram to the 
pint of water, in bleeding hemorrhoids, 
395, 829 

Phenol injection dangerous, 829 

Potassium chlorate, with laudanum, as an 
injection, 456 

Quercus, as an astringent wash, 462 

Stillingia, prescription for, 493 

Sulphur, to produce soft passages, 500 

Tannic acid suppositories often very useful 
in bleeding hemorrhoids, 509 

HEPATIC ABSCESS, 830 

Active treatment for dysenterv, if present, 

831 
Ammonium muriate, thought to be of 

value, 99 
Aspiration, when pus forms, 831 
Diet, 831 

Ipecac to prevent, 334 
Quinine and iron, after abscess develops, 

831 

HEPATIC CIRRHOSIS. 

Ammonium chloride, 99 

Iodoform, highly recommended, 331 

Liver, 3 oz. of fresh gland, in delirium of 

cirrhosis, and in alcoholic cirrhosis with 

icterus, 298 
Nitro-muriatic acid, in early stages, 398 
Potassium iodide, often useful in early 

stages, 323 
Sodium phosphate very useful, 489 

HEPATIC TORPOR. 

Ammonium chloride in, 99 

Citric acid in, 231 

Euonymus in, 289 

Nitro-hydrochloric acid when either acute 

or chronic, 398 
Potassium acetate very efficacious, 453 
Taraxacum, 510 

HEPATITIS (ACUTE), 830 

Cantharidal blister, small, over right hypo- 
chondrium; if impracticable, use mus- 
tard plaster, 830 

Hot cloths, over counterirritant, may re- 
lieve pain and aid in formation of blister, 
830 



Saline purgatives, preceded by calomel, 
gr. 1 (0.06), in divided doses, if constipa- 
tion exists, 830 

Sweet spirit of nitre with potassium citrate 
or diuretic waters to regulate kidneys, 
830 

HEPATITIS (CHRONIC AND SUB- 
ACUTE), 831 

Ammonium chloride, useful in subacute 
forms, 99 

Antisyphilitic treatment, if due to syphilis, 
831 

Aspiration, frequently repeated, may effect 
a cure, 831 

Nitro-muriatic acid, internally and exter- 
nally, most useful remedy, 398, 831 

Potassium iodide, useful in all cases, 831 

HERNIA. 

Chloroform or ether inhalations, to relax 
muscles during reduction, 208, 282 



HERPES. 



Anthrarobin in, 102 



Ipecac useful to prevent abscess, 334 Oil of amber, 92 



HICCOUGH, 831 

Amyl nitrite, 832 

Belladonna, 148 

Camphor, spirit of, dose, 1 dram (4.0), 
177 832 

Capsicum tincture, 1U 2 to 3 (0.12-0.2), 
832 

Chloral, 195 

Chloroform, 832 

Emetics or purges when gastric or intesti- 
nal irritation is present, 832 

Ether, sprayed on epigastrium. 283, 832 

Hoffmann's anodyne, especially valuable, 
307, 832 

Hot pack when due to uremia, 832 

Musk, gr. 10 (0.6), given by rectum, valu- 
able in all cases, especially in typhoid 
fever, 386, 832 

Nux vomica, accompanied by mineral 
acids, if due to indigestion, 832 

Oil of amber, m 5 to 10 (0.3-0.6), in cap- 
sule, one of the best remedies, 92, 832 

Sodium bromide and laudanum by the 
bowel when life is threatened, 832 

Valerian, tincture of, dose, 1 dram (4.0), 
832 

HYDROCELE. 

Ioidine, injections, after evacuation of the 
sac, the best curative remedy, 328 

HYDROCEPHALUS. 

Potassium iodide to cause absorption of 
fluids, 322 

HYPERTONIA. 

Atropine often acts as a specific, 148 

HYSTERIA. 

Calcium bromide, 163 

Corpus luteum, dried, has been used, 298 
Hops, as a nervous sedative, 309 
Hyoscine as a hypnotic, 317 
Monobromated camphor, to produce sleep, 
179 



1016 



INDEX OF DISEASES AND REMEDIES 



"Pill of three valerianates," 529 

Potassium bromide, 159 

Rest cure, 631 

Valerate of ammonium, 100 

Valerian, 529 

IMPOTENCE. 

Cannabis, with strychnine; nux vomica, 

or ergot, if no organic trouble exists, 

prescription for, 181 
Cantharis, with nux vomica and iron, may 

restore sexual power if loss is due to I 

excess, 183 
Gold, chloride of, and sodium, gr. ^ 

(0.003), 300 

INCONTINENCE OF URINE, 832 

Alkalies, 833, 834 

Ammonium benzoate or urotropin, gr. 4 
(0.25), in water, three times a day, if 
urine is concentrated and ammoniacal 
in odor, 833 

Antiseptic fluids, to cleanse bladder, in 
paralysis, 833 

Arsenic with nux vomica, in weakness of 
spinal centers, prescription for, 833 

Belladonna, if due to vesical spasm, 147, 
833 

Bromides with chloral, if due to vesical 
spasm, 160 

Buchu, with sweet spirit of nitre, valuable 
in some cases, 165 

Cantharides, TH. \ (0.03), with alkaline 
diuretics, thrice daily, in adults, 183, 834 

Catheterization, in retention or paralvsis, 
834 

Circumcision, if prepuce is redundant, re- 
lieves some cases, 833 

Fowler's solution, m \ to 1 (0.03-0.06), in 
chronic types due to atony, 834 

Hyoscyamus, if due to irritable bladder. 
316 

Potassium citrate, when due to acidity, 456 

Rhus aromatica, in incontinence of chil- 
dren, due to atony, 465 

Santonin, often valuable when other rem- 
edies fail, 476 

Strychnine, 834 

Sweet spirit of nitre and potassium citrate, 
if urine is dark and concentrated, pre- 
scription for, 507, 833 

Worms removed from vagina often cure, 
833 

INDIGESTION (GASTRIC AND 
INTESTINAL), 835 

Abdominal support if due to visceroptosis, 
835 

Alkalies, before meals in atonic states, dur- j 
ing or after meals when the secretion of I 
acid is excessive, 836 

Ammonium acetate solution as an antacid 
in gastric indigestion, 96 

Ammonium chloride, in painful forms, 99 

Asafoetida, in indigestion of old age, asso- I 
ciated with flatulence, 139, 840 

Bicarbonate of sodium with bitters, 836, j 
837, 838 _ 

Bitter tonics, useful in atony, contra- 
indicated in gastric irritation, 836 

Bromide of strontium, in excessive secre- 
tion, when not due to ulcer, 495, 838 



Byronia, when dependent upon gastric or 
intestinal atony, 164 

Carbolic acid and bismuth, 838 

Chloral, creosote, sodium thiosulphate, or 
thymol, with lavage, when fermentation 
is excessive, 838 

Chloroform spirit, Til xx (1.3), often of 
great value, 840 

Creosote, TU. \ to 2 (0.03-0.12), after meals 
in fermentation, due to deficient diges- 
tion of meats or the use of sweets, 253 

Diastase, when starchv foods are not 
digested, 256 

Diet, 836 

Fats, excluded in fermentative types, 838 

Gold, chloride of, and sodium, when epi- 
gastric pain is present, 300 

Hydrochloric acid, combined with carda- 
mom, in atrophy of the gastric tubules, 
cancer, or intestinal dyspepsia, 311, 836 

Hyoscyamus, belladonna, opium, bromides, 
bismuth, when there is hyperacidity, 837 

Lavage, 838 

Leptandra, of great value in intestinal 
types, prescription for, 354 

Massage, 840 

Nitrate of silver, especially when an ulcer 
is present, 837 

Nitro-hydrochloric acid or nitric acid, 
valuable in many cases, 394, 399, 839 

Ox-gall, 422 

Pancreatin, with sodium bicarbonate and 
alkaline mineral waters in intestinal 
types, 424, 839 

Papain, 425 

Pepsin, immediately after meals, 429 

Podophyllin or mercury, in lientery, 840 

Prescription for flatulence of intestinal 
indigestion, 451, 838, 839 

Prescription for torpid liver of indigestion, 
840 

Salol (phenyl salicylate) , in intestinal form 
with fermentation, 474 

Serpentaria, as a tonic, 483 

Test-meal, as a means of diagnosis, 835 

Thymol, beta-naphthol, creosote, chloral, 
and sodium thiosulphate in acidity due 
to acids of fermentation, 838 

Yellow oxide of mercury, gr. eV t° -gV 
(0.001-0.0012), in trituration, if there is 
foul belching or ill-smelling stools, 381 

INFLAMMATION. 

Acacia, in inflamed and irritated mucous 
membranes, 65 

Aconite, in acute, 75 

Bismuth in inflammation of mucous mem- 
branes, 154 

Cannabis, valuable in chronic types, 182 

Cantharidal blisters in deep-seated inflam- 
mations, 184 

Cocaine, in acute types, prescription for, 
234 

Cold applications, locally, 560 

Flaxseed, for inflamed mucous membranes, 
291 

Hop poultice, 309 

Liquor plumbi subacetatis, useful as a 
topical application, 353 

Opium, 416 

Silver nitrate useful in all inflammations 
of the pharynx, larynx, fauces, and 
mouth, 392 

Sulphurated lime, useful to check, 176 



INDEX OF DISEASES AND REMEDIES 



101' 



Tartar emetic, in sthenic inflammation, 105 
Turpentine stupe, 527 

INFLUENZA, 840 

Alcohol, 844 

Antipyrine, phenacetin, and acetanilide 
should be used only in small doses to 
allay pain, 841 

Aspirin, gr. 5 (0.3), with cinchonidinc sul- 
phate, gr. 3 (0.2), in capsule, very useful, 
841 

Barbital, barbital sodium, or sulphonal, for 
insomnia, 844 

Belladonna combined with strychnine, if 
there be vasomotor paresis, 843 

Blood from convalescents, 845 

Bromides, codeine, or morphine, if cough 
be excessive, 844, 845 

Cannabis, often valuable, if pushed, for 
irritative cough, 845 

Castor oil or magnesium sulphate, for con- 
stipation, 845 

Cold bath preferable to antipyretics, for 
reduction of temperature, 842 

Ergot, csnnabis, with bromides, often 
relieve vertigo, 845 

Medinal as a sedative, 844 

Monobromated camphor, 179 

Novaspirin, 403 

Phenacetin, 72 

Remedies for bronchitis when present, 844 

Salicin, 467 

Salol (phenyl salicylate) and phenacetin, 
valuable in combination, to allay irri- 
tation and pain, 841 

Sandalwood oil for excessive cough, 475 

Serum, blood, 845 

Steam inhalations, laden with vaporized 
drugs, for cough, 844 

Strychnine preferable to digitalis, if there 
be tendency to collapse, 843 

Sweet spirit of nitre, and citrate of potas- 
sium, in combination valuable in early 
stage, 841 

Vaccines, 844 

INSANITY. (See Mania, Acute.) 

INSOMNIA, 846 

Adalin, gr. 5 to 20, in capsule, useful in 

mild insomnia and nervous irritabilitv, 

76 
Barbital (veronal) in nervous insomnia, 

142, 846 
Barbital sodium (veronal sodium), 142, 

846 
Bath, cold, in cerebral anemia, hot, in 

nervous irritability, 562 
Bromide of strontium or sodium with 

Fowler's solution, in nervous females, 

prescription for, 160, 846 
Chloral, useful if not due to pain, prescrip- 
tion for, 195, 846 
Chloral and antipyrine if due to pain, 110 
Chloral formamide, gr. 15 to 60 (1.0-4.0), 

in wine or capsule, in nervous insomnia, 

197, 847 
Chlorestone, 197, 847 
Chlorobrom, for insomnia of melancholia 

and acute mania, 197 
Croton chloral preferable to chloral, if due 

to pain, 254 
Dial in place of barbital, 256, 846 



Dionin, to fortify veronal and sulphonal, 
267 

Drip-sheet in insomnia due to faulty cere- 
bral circulation or nervous tension, 565 

Duboisine more useful than hyoscine, 267 

Exercise if patient follows a sedentarj r life, 
848 

Hop pillow, 309 

Hot pack, in nervous insomnia, 596 

Hot-water bags to feet and cold to head, 
or general hot bath, 562, 847 

Hyoscine, gr. T J to f a (0.0006-0.0007) 



by mouth, or gr. 



to 



(0.0004- 



0.0006), hypodermically, in mania or 

hysteria, 317, 318, 847 
Luminal useful in nervous insomnia, 357 
Medinal (barbital sodium), 143 
Morphine with chloral, if due to pain, 

prescription for, 847 
Opium, only to be used in pain, 415 
Paraldehyde, 425, 847 
Potassium bromide in nervousness and 

overwork, 160 • 

Sodium bicarbonate if sleeplessness arises 

from acidity of stomach, 848 
Sulphonal, prescription for, may be given 

in hot water, 846 
Trional, in 15-grain (1.0) doses, 520, 846 
j Valerian, in nervousness, 529 

INTERMITTENT AND REMITTENT 
FEVER, 848 

I Alcohol, contraindicated during chill, 852 

Ammonium chloride in, 99 

Arsenic, in intervals between attacks, as 

an antiperiodic, 122 
j Arsphenamine, 851 

Calomel, gr. 1 (0.06) every fifteen minutes 
until 5 grains (0.3) are taken, four or five 
hours before quinine, if constipation is 
present, 851 
i Chloroform inhalations, preceded bylauda- 
num, by mouth or rectum, or mor- 
phine, gr. | (0.01), with atropine, gr. 
^0 (0.001), hypodermically, if death 
threatens during chill, 852 
I Cool drinks and sponging, in fevered stage, 
cold with friction, 852 

Digitalis or strychnine, to relieve internal 
congestion, during chill, 852 

Eupatorium, useful in, 289 

Ipecac or apomorphine, as an emetic, if 
chill follows full meal, 852 

Methylene blue, 1 to 4 grains (0.06-0.25), 
385 

Podophyllin, gr. T V to \ (0.006-0.008), pre- 
ceding quinine, if constipation is present, 
851 

Quinine, as a prophylactic and antiperiodic, 
849, 850, 851 



INTERTRIGO. (See Chapping.) 

INVOLUTION (ANOMALIES OF), 907 

Applications of nitric acid and silver 

nitrate useful in lacerations, 908 
\ Cannabis of great value in subinvolu- 
tion, 182 
Cimicifuga in subinvolution, 219 
Curette in subinvolution due to retention 
of hypertrophic endometrium, 908 



1018 



INDEX OF DISEASES AND REMEDIES 



Digitalis in subinvolution due to sluggish 

circulation, 908 
Ergo tin, gr. 1 (0.06), hydrastinin, gr. \ 

(0.03), and stypticin, gr. 1 (0.06), in pill, 

if due to fibroids, 271, 908 
Pituitrin (1 cc of 20 per cent, solution) is 

declared to be the strongest stimulant to j 

uterine contraction, 908 
Purgatives, disinfectants, and possibly hot | 

water locally applied, if due to inflam 

mation, 908 
Removal of placenta, if adherent, 908 

IRITIS, 854 

Arsphenamine and neoarsphenamine in 

syphilitic iritis, 855 
Atropine, the best local remedy, 148, 854 
Counterirritation, 580 
Daturine, scopolamine, or duboisine, when 

atropine cannot be used, 854 
Dionin, 5 per cent, solution, locally, for 

pain, 855 
Holocaine as a local anesthetic, 307, 855 
Hyoscine valuable for pain, 318, 855 
Iced compress, in early stage of traumatic ■ 

iritis, 854 
Iodide of potassium, alone or with mercury 

bichloride, following mercurial impres- 
sion, in syphilitics, 855 
Iridectomy required in some cases, 856 
Leeches and dry heat or hot fomentations, 

to relieve pain, 590, 854 
Mercury, preferably by inunction, if due 

to syphilis, 855 
Morphine, if pain is severe, 855 
Neisser's bacterin in gonorrheal iritis, 855 
Paracentesis, 854 
Pilocarpine, internally, if vitreous becomes 

opaque, also in gonorrheal types, 854 
Salicylate of sodium, or aspirin, in full dose 

in rheumatic iritis, 855 
Scopolamine in early stages of, and in \ 

plastic, 318, 481 
Subconjunctival injections of cyanide of 

mercury (1 : 5000-1 : 1000), or of salt, 

solution recommended in syphilitic iritis, 

855 
Tuberculin recommended in iritis due to 

tuberculosis, 855 
Vaccines, autogenous, have given admir- 
able results in certain forms, 856 

IRRITABILITY. 

Adalin useful, 76 

Almonds, as a drink in irritability of intes- 
tines and air-passages, 87 

Buchu in chronic vesical irritability, 165 

Cantharis, recommended in irritable blad- 
der of women and children, 183 

Cimicifuga, in uterine irritability, 219 

Hops, in vesical irritability, 309 

Hydrocyanic acid, in irritability of the 
stomach, 313 

Hyoscyamus, for vesical irritability with 
incontinence, 316 

Milk of magnesia in gastric irritability and 
acidity of adults and children, 360 

Petrolatum, as a soothing agent in gastro- 
intestinal types, 430 

Piperazine, in bladder irritation due to 
excess of uric acid, 447 

Potassium bromide, in irritability of the 
pharynx, 160 



Salicylates with bromides in nervous irri- 
tability of gouty or lithemic persons, 470 

Urotropin in irritability due to alkaline 
urine, 306 

JAUNDICE. 

Calomel, gr. $ (0.01) every half-hour until 
gr. 1 (0.06) is taken, if due to cold, 376 
Carbolic acid (phenol), gr. 10 (0.6), with 
water and glycerin, each 2 drams (8.0), 
locally applied in itching of jaundice, 
434 
Citric acid, in catarrhal form, 231 
Hydrastis, useful in subacute types, 310 
Iodoform, highly recommended, 331 
Manganese sulphate, may be tried in 

malarial types, 362 
Pilocarpine, useful unless due to malignant 

disease, 445 
Salol, said to be of value, 474 
Sanguinaria of service, 475 
Sodium phosphate of value, 489 

JOINTS (ENLARGED). 

Counterirritation, 579 

Leeches to swollen joints after sprains, 619 
Tartar emetic ointment as a counter- 
irritant in old enlargements, 106 
Turpentine liniment, 527 

JOINTS (INFLAMED). 

Alcohol, locally, as a wash, 81 
Camphor liniment, locally, 178 
Mustard to allay pain, 387 
Sodium salicylate or bicarbonate solution, 
to inflamed rheumatic joints, 471, 486 

JOINTS (RHEUMATIC). 

Oil of amber as a counterirritant over, 92 
Oil of gaultheria in acute and chronic rheu- 
matic joints, 295 
Phylacogens, 628 

Salicylic acid ointment useful, 471 
Veratrine ointment, 530 

KELOID. 

Ichthyol ointment, 319 
Thiosinamine, 10 per cent, solution in 
alcohol, injected into the growth, 514 

KERATITIS (INTERSTITIAL), 856 

Antiseptic lotions, in marked ciliary con- 
gestion, 856 

Antisyphilitic treatment, if due to syphilis, 
856 

Arsphenamine and neoarsphenamine, 856 

Atropine, in ciliary congestion, to prevent 
iritis, 856 

Diet and hygiene, 856 

Dionin valuable in 1 to 5 per cent, solu- 
tions, 267, 856 

Leeches to temple to relieve pain, if patient 
is not too young for bleeding, 856 

Thymol iodide, as a dusting-powder, 516 

Tuberculin efficacious in tuberculous cases, 
857 

KERATITIS (PHLYCTENULAR), 857 

Atropine, to relieve pain, 857 

Boric acid solution, to relieve congestion, 

857 



INDEX OF DISEASES AND REMEDIES 



1019 



Cocaine, not advisable in photophobia, 857 
Cold-water douche on closed eyelid, to 

relieve photophobia, 858 
Creolin solution, 1 to 2 per cent., as a wash, 

251 
Dark glasses, to protect eyes, 857 
Holocain solution, 2 per cent., to relieve 

pain, 307, 858 
Tonics and alteratives, with strict hygiene 

and regulated diet, associated with local 

treatment, 857 
Yellow oxide of mercury ointment, or 

calomel as a dusting-powder, to hasten 

cicatrization, contraindicated if iodine is 

being given, 857 

KERATITIS (ULCERATIVE), 858 

Antidiphtheritic serum, 860 
Antipneumococcus serum, 3 to 5 cc sub- 

cutaneously in ulcers due to pneumo- 

coccus infection, 860 
Antiseptic lotions, to limit sloughing, 858 
Atropine, instilled into eye, if there is any 

tendency to iritis, 859 
Cautery, actual, best means of preventing 

perforation, 859 
Curetting floor of ulcer, if perforation 

threatens, 859 
Dionin valuable in 1 to 5 per cent, solu- 
tions, 267, 859 
Eserine, instilled into eye, in peripheral 

ulcers, 859 
Holocaine as an anesthetic, 307, 859 
Hot compresses, 590, 859 
Massage of cornea and introduction of 

yellow oxide ointment to remove scars 

of ulcers, 860 
Paracentesis, 860 
"Pasteurization" of great value in infected 

corneal ulcer, 860 
Pressure bandage, if perforation threatens, 

859 
Silver nitrate, tincture of iodine, or tri- 
chloracetic acid applied to margin of 

ulcer, if there is a tendency to spread, 

859 
Subconjunctival injections of cyanide of 

mercury (1 : 5000) or of salt solution to 

absorb corneal nebula, 860 
Zinc sulphate, 1 per cent., touched to ulcer 

if Morax-Axenfeld bacilli are present, 859 

LACRIMAL ABSCESS, 861 

Division of canaliculi and washing out sac 
with antiseptic fluids, and insertion of 
probes into ducts after inflammation 
subsides, to restore patulency, 861 

Excision of lacrimal sac best surgical pro- 
cedure for chronic dacryocystitis, 861 

Formaldehyde (1 : 6000), silver nitrate 
(1 : 500), or protargol or argyrol (2 to 
5 per 100), injected through external 
opening if there is purulent discharge, 
861 

Hot compresses, to relieve pain, 861 

Puncture of abscess, if rupture threatens, 
861 

Window resection of nasal duct recom- 
mended by some, 861 

LARYNGISMUS STRIDULUS. 

Amyl nitrite, 102 
Belladonna, 148 



Bromide of potassium, 160 
Gelsemium, 296 

LARYNGITIS (ACUTE), 861 

Aconite to control fever, 862 

Antipyrine, as a spray, 112 

Bromides, useful in full doses, 60 to 120 

grains (4.0-8.0), a day, 160 
Calomel, small and repeated doses, fol- 
lowed by saline purges, along with hot 

mustard foot-baths and ' demulcent 

drinks, 862 
Creosote spray in subacute laryngitis, 253 
Cubeb cigarettes, useful for hoarseness of 

subacute forms, 255 
Freezing the skin over the insertion of the 

internal laryngeal nerve is a useful 

curative method, 863 
Inhalations in, 608 
Iodine, painted over throat, useful on 

third or fourth day, 863 
Iodol, 332 
Mustard plaster or hot applications over 

larynx, 862 
Nitric acid, dilute, TU 2 to 3 every half-hour 

or hour for six doses in early stage, 862 
Oil of amber and olive oil, half and half, 

well rubbed into the skin of the neck 

and chest, 93, 863 
Prescriptions for sprays, 862 
Silver nitrate, 392 
Steam inhalations, charged with benzoin; 

often advantageous to add menthol, 150, 
• 608, 861 

LEPRA. 
Arsenic, 122 

LEUCOCYTHEMIA. 

Arsenic, very useful in full ascending doses, 
122 

LEUCORRHEA, 863 

Alum, gr. 10 to 20 to the ounce (0.6-1.3 : 

30.0), as a vaginal wash, 91 
Ammonio-ferric alum, gr. 2 to 5 (0.12—0.3) 

in atonic types, 338 
Belladonna, gr. 1 to 2 (0.06-0.12), with 

tannic acid, gr. 6 to 8 (0.4-0.5), applied 

with cotton, in disease of uterine cervix, 

147 
Cantharidal collodion, applied over groins 

to produce blister, 864 
Goodell's prescription for, 864 
Hematoxylon, used internally, of service, 

304 
Hot sitz-bath, or vaginal injections of hot 

water, if due to uterine congestion, 590 
Hydrastis, injections, 310 
Iron, with tonics, if due to excessive lacta- 
tion or exhausting life, 863 
Myrrh, if due to uterine trouble, 388 
Nitrate of silver, when there is cervical 

ulceration, 393 
Potassium permanganate (dram \ [2.0] 

to water 1 pint [480.0]), as an injection, 

if discharge is fetid, 864 
Prescriptions for injection, 864 
Ringer's prescription for wash, 864 
Tampon, saturated with iodoform and 

tannic acid, 509, 865 
White oak bark (ounce 1 [30.0] to water 1 

pint [480.0]), or tannic acid and glycerin 

(ounce 1 [30.0] to 2 quarts [2 liters] of 

water), as an injection, 462, 864 



1020 



INDEX OF DISEASES AND REMEDIES 



LEUKEMIA. 

Oxygen inhalations, 422 

LICHEN. 

Arsenic, usually cures, 122 
Cantharides, 184 

Carbolic acid (phenol) ointment in lichen 
planus, 434 

LID ABSCESSES, 865 

Treatment same as for other abscesses, 865 

LITHEMIA. (See Gout.) 

LOCOMOTOR ATAXIA. 

Acetanilide, 69 

Antipyrine relieves lancinating pains, 111 

Arsphenamine (salvarsan), serum, 133 

Chloralformamide, prescription for, 197 

Co-ordinated movements in, 575 

Phenacetin, 72 

Potassium bromide, to prevent laryngeal 

crises, 160 
Salvarsanized serum, 133 

LUMBAGO, 865 

Acetanilide, dose, gr. 4 to 8 (0.25-0.5), 865 

Acupuncture, often relieves especially if 
pain is bilateral, 865 

Antipyrine, dose, gr. 5 to 10 (0.3-0.6), 865 

Aspirin, phenacetin, and salol, useful, 
combined or alone, 865 

Capsicum plaster useful, 185 

Chloroform liniment, 2 1 3 

Cod-liver oil, 240 

Ether or ethyl chloride spray locally, 866 

Foot-bath and Dover's powder, before 
retiring, often relieves, 865 

Hot poultice to back often useful, 865 

Ironing back with laundry iron, skin being 
protected by cloth or paper, very effi- 
cient, 590, 865 

Monobromated camphor, with other drugs 
very useful, 179 

Mustard or capsicum plaster or blister over 
painful spot may relieve, 866 

Potassium iodide or salicylic acid, if recov- 
ery is slow, 322, 865 

Salicylic acid, useful, 470, 865 

Strapping often relieves sacro-iliac pain, 
866 

Turpentine, gtt. 20 (1.3), said to be useful, 
527 

LUPUS. 

Acid nitrate of mercury, 380 

Carbon-dioxide snow in lupus erythemato- 
sus, 560 

Ichthyol ointment, 319 

Iodine, as a paint, to retard spread, 327 

Thiosinamine, useful in, 514 

MALARIAL FEVER. (See Intermit- 
tent and Remittent Fevers.) 

Antipyrine, 111 

Arsenic, as a cure and prophylactic, 120, 

122 
Arsphenamine (salvarsan) useful, 224, 851 
Calomel, 370 
Eucalyptus, instead of quinine, when it 

cannot be borne, 288 
Gelsemium, of doubtful value, 296 



Hydrastis, said to be antimalarial, 310 
Methylene blue, 1 to 4 grains (0.05-0.2), 

384 
Quinine, the best remedy as a prophylactic 

and a cure, 223 
Warburg's tincture, said to excel quinine 

in pernicious malarial regions, 533 

MALARIAL FEVER (PERNICIOUS), 

852 

Morphine and atropine, hypodermically, 
to control retching and vomiting, 853 

Quinine, 10 to 15 grains, intravenously, 
853; must be used with great caution in 
hematuric or hemoglobinuric type, and 
not at all unless the malarial organism 
can be found in the blood, 853 

Sodium thiosulphate, 60 grains every two 
or three hours, in malaria hematuria, 
853 

Water, copiously, with or without lemon 
juice, to flush the kidneys, 853 

MANIA (ACUTE), 866 

Anesthetics, or apomorphine in emetic 
dose, to relax muscular system, if patient 
is very violent, so that other remedies 
may be administered, 866 

Bromide of potassium, as a soporific, 160 

Cannabis, with large doses of bromides, 
particularly serviceable, 866 

Chloral, in full doses, if kidneys are healthy, 
866 

Cold douche to head while body is im- 
mersed in hot water, often of service, 866 

Duboisine, for insomnia, 267 

Hot-steam bath or Russian bath valuable, 
866 

Hyoscine hydrobromide, gr. jfo (0.0006), 
when necessary to quiet patient quickly, 
317, 866 

Morphine, in full dose, may be required to 
quiet patient, 866 

Sulphonal as a hvpnotic, 499 

Thyroid gland, gr. 5 to 20 (0.3-1.3), 518 

MARASMUS. 

Cod-liver oil inunctions, one of the best 
remedies, 240 

Mercury with chalk in syphilitic maras- 
mus, 379 

MASTITIS. See Breast, Inflamed.) 

MELANCHOLIA, 866 

Nitro-muriatic acid, VC[ 5 (0.3), in water 
after meals, if associated with oxaluria, 
399, 866 

Phosphorus, useful in some cases due to 
overwork, 439 

Thyroid gland, gr. 5 to 20 (0.3-1.3), 518 

MENINGITIS (ACUTE), 867 

Alcohol, given with food in second stage, 

if there be asthenia, 867 
Antimeningitis serum is only remedy of 

real value, 552, 867 
Blister to nape of neck, in early stage, to 

prevent effusion, also in comatose state, 

867 
Bromides and chloral, best agents to allay 

nervous symptoms, 867 



INDEX OF DISEASES AND REMEDIES 



1021 



Ice-bag to head, in early stage, 562, 867 
Leeches to nape of neck, in early stage, 

619, 867 
Lumbar puncture, if symptoms of cerebral 

pressure are marked, 621, 867 
Milk diet, in second stage, 867 
Opium, useful in second stage, 415, 416 
Quinine, contraindicated in acute stage, 

867 

MENINGITIS (CHRONIC). 

Phosphorus, 439 

MENOPAUSE. 

Bromide of potassium, in nervous dis- 
orders, 159 

Cannabis, alone or with aloes and iron, 
if anemia or constipation exist in head- 
aches of the menopause, 181 

Corpus luteum useful, 250 

Eau de Cologne, saturated with camphor, 
locally applied in headache or drowsi- 
ness, 178 

Ovarian extract, for nervous and nutri- 
tional disturbance, 421 

Valerate of ammonium, in nervous dis- 
orders, 100 

MENORRHAGIA AND METROR- 
RHAGIA, 824 

Adrenalin chloride (1 : 5000) may be em- 
ployed, 504, 824 

Bromide of potassium or sodium, gr. 10 
(0.0) once or twice dailv, if bleeding is 
irregular, 160, 824 

Cannabis, recommended, 181, 824 

Cinnamon oil, dram h (2.0), when erig- 
eron is not at hand, in oozing flow, 824 

Cotarnine useful, 251, 824 

Dry cups over sacrum, if due to conges- 
tion, 824 

Ergot, fluidextract, m 10 to 60 (0.6-4.0), 
best remedy in active bleeding, 271, 824 

Erigeron, oil of, 111 3 to 5 (0.2-0.3), in 
capsule or emulsion, the best remedy 
for oozing, 272, 824 

Hamamelis, water of, dram 1 (4.0) thrice 
daily, in irregular bleeding, 824 

Monsel's solution (50 per cent.), full 
strength locally applied if due to poly- 
pus, 342 

Rhus aromatica highly recommended in 
menorrhagia, 465 

Rue, in atonic menorrhagia, 466 

Savine, oil of, m 5 to 10 (0.3-0.6), in cap- 
sule or emulsion, every three or four 
hours, as a tonic in menorrhagia, 478 

Turpentine, often of value, 527 

MENSTRUATION. 

Aconite in suppression of, due to cold, 75 
Corpus luteum seems to do good in scanty 

menstruation, 250 
Rest cure in disorders of menstruation, 632 
Turkish bath, 592 

MIGRAINE, 867 

Ammonium benzoate, gr. 10 to 20 (0.06- 
1.3), 868 

Amyl nitrite, 102 

Bromide of potassium, with caffeine, al- 
most a specific, if due to eye-strain, 160 



Cannabis, extract, gr. f to h (0.015-0.03), 

with tincture of gelsemium, gtt. 10 to 

20 (0.6-1.3), every two hours, 181, 868 
Corpus luteum in menstrual migraine, 250 
Croton chloral, very efficient, especially if 

fifth nerve is involved, 254 
Gelsemium, with cannabis, to abort, 296, 

868 
Menthol pencil useful externally, 428 
Methylene blue, gr. 1 to 2 (0.06-0.12), in 

capsule, 385 
Phenacetin, 72 

Rachford's prescription for, 868 
Salicylic acid, of great service in rheumatic 

types, 470, 868 
Sodium phosphate, in hot water taken in 

morning, 868 
Starr's prescription for, 869 

MILK DEFICIENCY, 910 

Bier's cups, to produce local hyperemia, 

have proved efficient, 911 
Electricity, 911 
Pituitrin, 911 

Placental extract under trial, 911 
Treatment for intercurrent affection, if due 

to such cause, 910 

MORPHIOMANIA. (See Poisoning 
from Opium, Chronic.) 

Bromide of potassium, 160 
Hyoscine, in full dose, 317 
Phosphorus, of service in sequela? of mor- 
phiomania, 439 

MUCOUS MEMBRANE (DISEASES 
OF). 

Acacia, as a mucilaginous drink in irrita- 
tion and inflammation of upper air 
passages, 65 

Bismuth, as an astringent, to inflamed 
membranes, 154 

Flaxseed, as a soothing demulcent, 291 

Glycerole of aloes, locally applied to fis- 
sures, valuable, 90 

Opium, suppositories, gr. f (0.015), useful 
in rectal inflammation, if not an acute 
catarrh, 416 

Pareira, useful in chronic genito-urinary 
inflammation, 426 

Tannic acid, useful in depressed condi- 
tions, 509 

Terebene, useful in subacute and chronic 
genito-urinary inflammation, instead of 
sandalwood or copaiba, 511 

Zinc sulphate, weak solution, as an astrin- 
gent, 536 

MUSCJE VOLITANTES, 869 

Alteratives and correction of anomalies of 
refraction, 869 

MUSCULAR STIFFNESS. 

Hot laundry iron passed over part, skin 
being protected by layers of paper or 
cloth, often relieves, 590 

MYALGIA, 869 

Ammonium chloride, if due to cold or 

bruises, 869 
Camphor liniment, 178 
Chloroform liniment, 870 



1022 



INDEX OF DISEASES AND REMEDIES 



Cimicifuga, fluidextract, T([ 20 to 1 dram 
(1.3-4.0), 869 

Clove oil, added to liniment, as a counter- 
irritant, 232 

Iodide of potassium or salicylates, if due 
to rheumatism, 869 

Iodine ointment, pure or diluted with lard, 
869 

Massage or good rubbing, very necessary, 
870 

Potassium acetate or citrate, gr. 20 (1:3), 
may be tried, 869 

Poultices, hot as can be borne, 870 

Prescription for liniment, 870 

MYXEDEMA. 

Thyroid gland, or extract of, a specific for, 
517 

NASAL CATARRH (ATROPHIC), 870 

Dobell's solution, as a cleansing wash; 
carbolic acid may be increased, or 
thymol and eucalyptus substituted for 
it, to relieve odor, 156, 870 

Galvano-cautery, or strong silver nitrate 
solution, if ulcerations are present, 871 

Hydrogen peroxide, 871 

Ichthyol, useful, 871 

Iodine and glycerin, with potassium iodide, 
sufficient to cause solution of the iodine, 
valuable locally applied, 871 

Potassium iodide internally, tonics and 
stimulants to mucous membrane, and 
attention to activity of skin, 871 

Potassium permanganate, useful; painful 
if sensation is not entirely lost, 871 

Removal of necrosed bone, 870 

Silver nitrate and starch (gr. 1 to 10 [0.06- 
0.6] to drams 2\ [10.0]), as an insuffla- 
tion powder, or solution (gr. 1 to 10 
to the ounce [0.06-0.6:30.0]), better 
in some cases, locally applied, 871 

NASAL CATARRH (CHRONIC), 871 

Alkaline wash, 872 

Arsenic, 123 

Camphor, 177 

Ferric alum (gr. 5 to the ounce [0.3 : 30.0]), 
useful, in spray, in later stage, 872 

Galvano-cautery or snare, to remove hy- 
pertrophic tissue remaining after acute 
stage, 872 

Hydrastis, dilute solution or distilled 
extract of hamamelis and water, equal 
parts, useful in spray, in acute stage, 
310, 872 

Iodine and glycerine (gr. 6 to 8 to the 
ounce [0.4-0.6 : 30.0]), with potassium 
iodide, sufficient to cause solution of 
the iodine locally applied, 872 

NAUSEA. (See Vomiting.) 

Hoffmann's anodyne, when due to exces- 
sive use of tobacco, 307 

Hydrocyanic acid, dilute, HI 3 (0.2), in 
water, often useful, 312 

Lime-water, 174 

Seidlitz powder, when associated with con- 
stipation, 481 

NEPHRITIS (ACUTE), 873 

Aconite, to depress circulation, 873 
Blisters contraindicated, 873 



Bromides or opium, given cautiously, if 

aconite fails to quiet restlessness, 873 
Caffeine, in later stages, 874 
Cannabis, if hematuria is present, also 

to allay pain over kidney, 182, 873 
Cantharides, \ to 1 1U (0.03-0.06) of 

tincture about fifth day, when kidneys 

are atonic, also if hematuria is present, 

873, 874 
Citrate of potassium and sweet spirit of 

nitre, to increase flow of urine, 873 
Cups or leeches over loins if urine is scanty, 

873 
Digitalis with squill or calomel, gradually 

increased, followed by gin or compound 

spirit of juniper in later stages, 262, 874 
Elaterium, to relieve dropsy, 873 
Flaxseed tea, as a demulcent, 291, 873 
Hot-air baths, useful to provoke sweat, 874 
Iron, if anemia be present, also to decrease 

albuminuria, 874 
Juniper, to re-establish secretion, after 

inflammation has subsided, 345, 874 
Meat-free diet, 874 



Pilocarpine hydrochloride, gr. 



to \ 



(0.003-0.008), hypodermically, if uremia 
threatens, repeated in fifteen minutes 
if no sweat appears, but guarded by 
strychnine when the heart is weak, 445, 
873 

Potassium bitartrate, 454 

Sulphate of magnesium, gss (10.0), or 
calomel, to aid in elimination of toxic 
products by bowel, 873 

Turkish bath, to aid in eliminating effete 
products, used with care, 592 

NEPHRITIS (CHRONIC), 874 

Ammonium acetate useful in parenchyma- 
tous type, 875 

Basham's mixture for anemia, 338, 875 

Bichloride and protiodide of mercury, 374, 

381 
1 Capsicum, to check albuminuria, 185 

Chloride of gold and sodium have been 
recommended in interstitial forms, 300 

Chloride of iron if anemia is present; also 
to decrease albuminuria, 339, 876 

Diet, 874, 875, 876 

Digitalis and caffeine useful, 262, 875 
' Elaterium or jalap, to relieve dropsy, 876 

Electric cabinet bath, 876 

Hot baths, or hot pack, 877 

Juniper of value, 345 

Methylene-blue solution hypodermically, 
when kidney is suspected of being inade- 
quate, 385 

Nitrite of sodium useful in ascending doses 
in chronic interstitial nephritis, 396, 875, 
876 

Nitroglycerin, with cardiac disturbance 
and high arterial tension, 396, 877 
I Potassium acetate or bitartrate combined 
with digitalis, or the bitartrate combined 
with gin or compound infusion of juniper, 
454, 876 

Potassium iodide, gr. 5 (0.3) thrice daily 
used with great care, in contracted 
kidney, 323 

Proteins often needed, 874 

Protoiodide of mercury useful, 381 

Salt-free diet in, 875, 876 

Sodium iodide of great value in many 
cases, 877 



INDEX OF DISEASES AND REMEDIES 



1023 



Squill, 492 

Strontium lactate, for the relief of albu- 
minuria, 492 

NERVOUSNESS. 

Ammonium valerate in nervous unrest of 
pregnancy, or hysteria, 100 

Asafoetida in nervous irritability of chil- 
dren, 139 

Bromides, 159 

Camphor, as a sedative, 177 

Corpus luteum in nervous disturbances 
during artificial menopause, 250 

Hops, as a sedative, 309 

Lecithin used when there is nervous ex- 
haustion, 353 

Musk useful in nervous excitement and col- 
lapse, only to be used through crisis, 386 

Phosphorus, in nervous debility and ex- 
haustion, 439 

"Pill of three valerianates," highly recom- 
mended, 529 

Rest-cure very useful where nervousness 
is due to exhaustion, 631 

Strychnine, in functional nervous atony or 
depression, 405 

Sumbul, prescription for, 502 

Suprarenal gland, 504 

Sweet spirit of nitre, in nervous excite- 
ment of fever and other nervous states of 
infancy, 507 

Valerian, alone or with other drugs, 529 

NEURALGIA, 877 

Acetanilide useful especially with mono- 
bromated camphor, 69, 878 

Aconite ointment (gr. 2 to the dram [0.12 : 
4.0]), or oleate of aconitine (gr. 2 [0.12] 
to sweet oil 100 minims [6.6]), useful 
applied over painful spot, if limited in 
area, 75 

Acupuncture, nerve-stretching, or neurec- 
tomy, necessary in some cases, 879 

Alcohol, 90 per cent,, with 4 gr. (0.24) of 
cocaine to the ounce (30.0), injected 
locally in quantities of 15 to 30 minims 
(1.0-2.0), 879, 880 

Ammonium chloride, in ovarian neuralgia, 
99 

Amyl nitrite, inhalations, when due to 
anemia, 879 

Antipyrine, with chloral, very useful, 
especially in gout, rheumatism, or 
nervous depression, 110, 878 

Aspirin, 5 to 20 grains (0.3-1.3), in tablet 
or capsule, is very efficacious, 141, 878 

Belladonna, 146, 148 

Bromide of potassium with caffeine, al- 
most a specific, 160, 878 

Camphor liniment, locally applied, to 
relieve pain, 178 

Castor oil, oz. 1 to 2 (30.0-60.0) a day, at 
times gives good results, 190, 879 

Chloral formamide, 197 

Chloral locally, prescription for, 196 

Chloretone and antipyrine (3 to 6 grains 
[0.2-0.4]), 198 

Chloroform liniment, as a local anesthetic, 
213 

Cimicifuga, especially useful in ovarian 
types, 219 

Cod-liver oil, 240, 877 



Cold applications, locally, 562, 879 

Croton chloral, gr. 5 to 20 (0.3-1.3) in 5- 
grain pills, often effective in brow 
neuralgia, 254, 879 

Freezing parts with chloride of ethyl, 
ether or rhigolene spray or by small 
packages of ice and salt, 282, 561, 879 

Guaiacol used locally of value, 303 

Heroin, gr. f 5 (0.005), useful, 879 

Hydrocyanic acid useful in intestinal 
neuralgia, 314 

Iodide of potassium, may be tried in rheu- 
matic neuralgia, 322 

Iron and arsenic, in anemia; often neces- 
sary to associate with them bitter tonics 
and cod-liver oil, 877 

Magnesium sulphate solution locally, 361 

Menthol locally, 428, 879 

Morphine, gr. I to i (0.012-0.015), in- 
jected into painful spot, if localized; not 
advisable in chronic cases, 879 

Muriate of ammonium, useful in ovarian 
types, 98 

Mustard plaster, as a counterirritant, 387 

Neurectomy, 879 

Novaspirin, 403 

Nux vomica or strychnine, if nerve is de- 
pressed by anemia, 878 

Peppermint oil, locally applied on cloth 
over painful spot, 427 

Phenacetin, gr. 3 to 8 (0.2-0.5), very use- 
ful, prescription for, 72, 878 

Phosphorus, if due to nervous exhaustion, 
439 

Potassium iodide, 322 

Prescriptions containing antipyrine with 
bromides and caffeine, 160, 878 

Quinine, if due to malaria, 878 

Rest-cure very useful in exhausted pa- 
tients, 632 

Salol (phenyl salicylate) , if due to exposure, 
474 

Salophen, useful when combined with 
phenacetin, 475 

Specific remedies, if due to scrofulosis or 
syphilis, 878 

Turkish baths, may relieve if due to rheu- 
matism or gout, 592 

Veratrine ointment, locally applied, over 
neuralgic nerve, 530 



NIGHT-SCREAMING. 

Bromide of potassium, 160 



NIGHT-SWEATS. 

Acetic acid, as a lotion, diluted one-half, 70 

Agaricin, of doubtful value, 77 

Alum dissolved in water or alcohol, effi- 
cient application for sponging, 91 

Belladonna, one of the most powerful 
remedies we have, 147 

Camphoric acid, the best of all remedies, 
180 

Ergot, 271 

Gallic acid, 293 

Pilocarpine, gr. & (0.003), hypodermically, 
two hours belore sweat, often useful, 
even when atropine fails, 445 

Sulphuric acid, with belladonna or mor- 
phine, often useful, 502 

Zinc oxide, prescription for, 536 



1024 



INDEX OF DISEASES AND REMEDIES 



NIPPLES (SORE), 881 

Benzoin, tincture, locally applied, 881 
Boric acid (gr. 20 to the ounce [1.3 : 30.0]) 

or mucilage of acacia, applied after 

nursing, nipple being dried beforehand, 

881 
Breast-pump or nipple-shield may be 

necessary to effect cure, 881 
Cocaine (gr. 4 to the ounce [0.25 : 30.0]) 

applied and washed off before nursing, 

if breast is very painful, 234, 881 
Ichthyol, when indurated, 319 
Prophylaxis, 881 
Silver-nitrate stick touched to fissure, if 

deep and slow to heal, 881 
Tannin, glycerite of, locally applied, 881 

NYMPHOMANIA. 

Bromide of potassium, of great service, 160 
OBESITY, 881 

Acetic acid, harmful, 70 

Cold bath, 884 

Diet, 882, 883, 884 

Laxative fruits and purges, to regulate 
bowels, 884 

Massage, passive movements, absolute 
skimmed-milk diet, and electricity, if 
exercise is impracticable, 884 

Potassium permanganate, 430 

Saline purges, 884 

Thyroid gland, 517, 885 

OPHTHALMIA. (See Conjunctivitis.) 

OPHTHALMIA (SYMPATHETIC), 885 

Arsphenamine and neoarsphenamine have 
been used with good effect, 885 

Aspirin in large doses, 885 

Atophan, 40 to 60 grains daily, and benzo- 
salin in full dose have been recom- 
mended, 885 

Atropine, unless there is a rise in tension, 
885 

Benzosalin in full doses, 885 

Mercury internally to by inunction should 
be tried, 885 

Phenylcinchonic acid gr. 40-60 (2.6-3.9) 
daily, 885 

Preventive enucleation of originally in- 
jured eye, if treatment is unavailing, 885 

Sodium salicylate, in very large doses, 
does most good, 885 

OPIUM HABIT. (See Poisoning 
from Opium, Chronic.) 

OPTIC NEURITIS AND OPTIC 
NERVE ATROPHY, 671 

Arsphenaminized serum of value intraspin- 
al! y in tabetic atrophy if used early, 672 

Bromide of potassium, 671 

Fly blisters to temple in some cases, 671 

High-frequency currents should be tried, 
672 

Iodide of potassium, silver nitrate, phos- 
phorus, arsenic, iron, santonin, lactate ' 
of zinc, antipyrine and injections of j 
organic liquids, all of doubtful value, 672 

Negative galvanism has been advised, 672 



Radium and Roentgen rays have not 
proved useful, 672 

Sinusoidal current recommended, 672 

Strychnine, in full doses, enforced by nitro- 
glycerin or inhalation of amyl nitrite, 
672 

Trephining to relieve intracranial pressure, 
671 

ORCHITIS. (See Epididymitis.) 

OSTEOMALACIA. 

Corpus luteum in, 298 
Phosphorus, 439 

OTITIS MEDIA. (See Earache.) 

Dermatol as a dusting-powder in purulent 

forms, 153 
Potassium permanganate, gr. 1 to oz. 1 

(0.06-30.0), as a wash, 430 

OTORRHEA. 

Creolin solution (1 : 500), used with 
syringe, 251 

OXALURIA. 

Nitric acid, 394 
Nitro-hydrochloric acid, 399 

OZENA. 

Ichthyol, very useful in fetid ozena, 320 
Prescriptions for insufflation powder, 371 
Scarlet red, 479 

PARALYSIS AGITANS. 

Cannabis, to quiet tremors, 181 
Chloral, of great service, 195 
Duboisine sulphate of some use, 268 
Parathyroid gland, 426 
Sparteine, 480 

PARASITES. 

Bichloride of mercury (gr. 2 [0.12] to water 
oz. 1 [30.0]), applied thrice daily in para- 
sitic skin diseases, 374 

Cajuput oil, applied pure, will destroy 
pediculi, 169 

Chrysarobin, gr. | (0.008), internally, or 
the ointment, with benzoated lard (1:4 
or 5), locally applied, in parasitic skin 
diseases; must not be used on face, 218 

Mercurial ointment, useful to destroy 
pediculus pubis or other parasites, 380 

Oil of cloves, 232 

Pyrogallol, 30 grains to the ounce (2.0 : 
30.0), for parasitic skin disease of pso- 
riasis, 461 

Thiosulphate of sodium, 1 dram to the 
ounce (4.0 : 30.0), for parasitic skin dis- 
ease, 490 

Volatile or fixed oils, useful to destroy, 380 

PARTURITION./^ 

Antipyrine for pains, of doubtful value, 111 
Castor oil, to relieve constipation, 189 
Chloroform, 209 

Quinine, as a stimulant to uterus, 225 
Scopolamine and morphine to relieve pains. 
481 

PEMPHIGUS. 

Arsenic, 122 



INDEX OF DISEASES AND REMEDIES 



102, 



PERICARDITIS, 885 

Aconite, to allay inflammation and quiet 

heart, 75 
Alcohol, digitalis, or caffeine, if heart shows 

signs of failure, 886 
Aspiration, gradual, if exudation endangers °""™ ^Itf. siage + s ' ?°° 

life 886 lurkish bath m acute forms when ph 

Blister, over the precordium, often useful, feels raw ' 592 



Potassium chlorate, as a gargle, 455 
Salol (phenyl salicylate), in 5-gr. (0.3) 

doses, 474 
Silver nitrate solution, in varying strength, 

locally applied, 392 
Silvol in early stages, 485 

" arynx 



Cardiolysis, when adhesions interfere with 
heart action, 886 

Elaterium, useful in effusions, 268 

Ice-bag over the precordium, very useful, 
562, 885 

Iodide of potassium, to aid in absorption 
of fluid, 322 

Leeches, 5 to 10, over precordium, accom- 
panied by large dose of veratrum viride 
in early stages of sthenic cases, 885 

Opium, to allay inflammation, 416 

PERITONITIS (ACUTE), 886 

Acetanilide, gr. 2 (0.12), every two or three 
hours, with brandv and ice, for vomiting, 
888 

Counterirritation, 581 

Enteroclysis, 888 

Ice for thirst. Vomiting does not contra- 
indicate small amounts of water, 888 

Ice-bag or turpentine stupe to abdomen; 
leeches in sthenic cases, 888 

Lavage, gastric, often advantageous, 888 

Murphy drip in post-operative or septic 
peritonitis, 888, 889 

Opium pushed until pain is relieved, but 
never to the point of obtunding intelli- 
gence, 416, 888 

Rectal tube, milk of asafcetida or turpen- 
tine injections, in tympanites, 891 

Salines, useful in cases following surgical 
operations, but contraindicated by 
feebleness, perforation, or obstruction, 
890 

Surgical procedures, often necessary; when 
diagnosis is obscure or in septic general 
peritonitis exploratory incision is justi- 
fied, 888 

PERITONITIS (CHRONIC), 891 

Incision, with or without drainage and 
iodoform useful in tubercular peritonitis. 
891 

PERNICIOUS MALARIAL FEVER, 852 

Morphine and atropine to control retching 

and vomiting, 853 
Quinine, large doses, in solution, by mouth, 

rectum, or hypodermically, 225, 853 
Thiosulphate of sodium, gr. 60 (4.0), to 
• move the bowels, 853 

PHARYNGITIS. 

Antipyrine, in 4 per cent, spray, 112 

Cocaine, gices temporary relief; after- 
effects bad, 235 

Cubebs, troches of, used in chronic types, 
255 

Monsel's solution, pure or diluted one- 
half with glycerin, applied on pledgets of 
cotton or camel-hair brush, 342 
65 



PHTHISIS. (See Tuberculosis.) 

PITYRIASIS VERSICOLOR. 

Anthrarobin in, 102 

Sodium thiosulphate, 1 dram to the ounce 
(4.0-30.0) of water or lard useful, 490 

PLEURITIS OR PLEURISY, 891 

Aspiration, when hydragogue purges fail 

to remove effusion, 893 
Bryonia in pleurisy with effusion, 165 
Cantharidal blister, two inches below 

axilla, aids absorption of effusion, 579, 

893 
Cotton jacket, 892 
Dakin's solution. 894 

Elaterium or jalap, useful to remove effu- 
sion, 268 
Gelsemium, 296 
Hychlorite, 895 
Iodide of potassium, used in chronic stage, 

to aid absorption. 322 
Iodine, locally applied, to abort, and aid 

absorption of fluid, 327 
Pilocarpine, 445 
Pulmonary exercises in deficient expansion 

because of adhesions following an attack, 

604 
Salicylates very useful for the removal of 

effusion, 470 
Saline purges, in second stage, to remove 

effusion, 893 
Strapping chest, if respiratory movements 

are very painful, 891 

PLEURODYNIA. (See Neuralgia.) 

PNEUMONIA, 895 

Aconite, preferable to veratrum, in early 
stage, in children, 75 

Alcohol, inferior to digitalis, as a cardiac 
stimulant in the second stage in adults, 
but better in children, 81, 897 

Ammonia useful for adults and children 
94 

Ammonium bromide and carbonate may 
be used if morphine cannot be used, 900 

Ammonium chloride, as an expectorant in 
third stage, 900 

Antipneumococcic serum, 553 

Asafcetida, by rectal injections, in tym- 
panites, 139 

Barbital sodium, 5-10 gr. (0.3-0.6) for 
insomnia, 899 

Belladonna, very useful, if there are evi- 
dences of collapse, 148, 898 

Camphor in almond oil hypodermically in 
sudden depression, 177 

Citrate of potassium to maintain renal 
activity, 899 

Climatic treatment in convalescence, 624 

Cold compresses, locally, 897 

Cold sponging for fever, 897 



1026 



INDEX OF DISEASES AND REMEDIES 



Convalescent blood or serum in influenzal 
pneumonia, 845 

Counterirritation in, 579 

Digitalis, tincture, TTl 10 (0.6), every eight 
hours, accompanied by belladonna, 1U 10 
(0.6), every four hours, carefully 
watched in second stage, 262, 897 

Dover's powder for pain at onset, 896 

Ethylhydrocuprein hydrochloride an effi- 
cient destroyer of pneumococci, 287 

Fresh air, 895 

Gelsemium, in early stages, 296 

Gin, to maintain renal activity, 86, 345, 
899 

Heroin, gr. ^ (0.005) every eight hours, 
for excessive cough, 900 

Ice-bag to heart if fever be high and heart 
tumultuous, 562, 897 

Iodide of potassium, in later stages to ab- 
sorb exudates, 323 

Morphine, for pain at onset, and for exces- 
sive cough and persistent insomnia, 416, 
896, 899 

Oxygen inhalations if asphyxia threatens, 
422, 898 

Phosphorus, 439 

Phylacogens, 628 

Pulmonary exercises in delayed resolution, 
604 

Spirit of ether or aromatic spirit of ammo- 
nia, 1 dram of each every hour if collapse 
threatens, 898 

Strychnine as a respiratory and circulatory 
stimulant in second stage and as an 
adjuvant to digitalis, 405, 898 

Sweet spirit of nitre to maintain renal 
activity, 899 

Vaccines are a prophylactic, 641 

Venesection, in early stage of sthenic cases, 
cardiac depressants preferable, and late 
when heart is laboring and veins dis- 
tended, 645, 898 



POISONING FROM— 

Acetanilide. 

Supportive measures, stinulants, external 
heat, belladonna to maintain blood- 
pressure, strychnine to counteract res- 
piratory failure, and oxygen inhalation 
to overcome cyanosis, 68 

Acetate of Zinc. 

Treatment same as for Gastro-enteritis, 533 

Acetic Acid. 

Large amounts of milk, alkaline liquids, 
and general treatment for gastro-enter- 
itis, 71 

Aconite. 

Keep patient in prone position, with feet 
higher than head. Hot applications; 
emetics contraindicated ; evacuate stom- 
ach by siphon or stomach-pump. Ether ! 
hypodermically, followed by alcohol ! 
and this by digitalis. Artificial respira- 
tion and amyl nitrite a few whiffs, no 
more, if heart fails; atropine, strychnine, i 
74 



Alcohol (Acute). 

External heat, digitalis and strychnine 
hypodermically, in coma, if heat fails. 
Belladonna, if the skin is relaxed and 
clammy, and counterirritation to nape 
of neck for brain symptoms. After- 
treatment, ammonia, spices, spirit of 
Mindererus; emollients in gastritis, ice, 
aconite, hydrochloric acid, or ipecac in 
minute dose, and counterirritation for 
vomiting. Jalap, gr. 40 (2.6), elaterium, 
gr. £ (0.01), or calomel and salines, as 
purgatives, 82 

Fowler's solution for morning vomiting, 82 

Alcohol (Chronic). 

Withdrawal of drug, at once or gradually. 
Highly seasoned broths, predigested 
food, and morphine or coca, in small 
dose, if weakness is marked. Capsicum, 
prescriptions (page 84), 84, 185 

Antimony. 

Large doses of tannic acid, external heat, 
alcohol, digitalis, and opium hypoder- 
mically, if respiration is not too feeble. 
If necessary to use opium, it should be 
accompanied by strychnine. Prone 
position, patient vomiting into towels. 
Stomach-pump, if vomiting is absent, 
106 

Antipyrine. 

Maintain bodily heat, stimulants, atro- 
pine, and oxygen inhalations, if cyanosis 
is alarming, 109 

Arsenic (Acute and Chronic). 

Stomach-pump, external heat, stimulants 
and the chemical antidote, hydrated 
sesquioxide of iron and magnesia. Mag- 
nesia also useful by itself. Opium should 
follow antidote, to allay pain, also large 
draughts of water to flush kidneys and 
dilute poison. For chronic poisoning, 
iodide of potassium, tonics, electricity, 
and out-of-doot life, 127, 129 

Belladonna. 

External heat if collapse intervene, and 
strychnine to support respiration. The 
physiological antidote, opium, may be 
carefully given, 146 

Carbolic Acid (Phenol). 

Soluble sulphates, as Epsom or Glauber 
salts, warm mucilaginous drinks, hot 
applications to extremities, digitalis, 
strychnine, and counterirritation over 
abdomen. Emetics and stomach-pump 
should be used if possible, 432 

Chloral. 

External heat, emetics in early and stom- 
ach pump in later stages. Strychnine or 
atropine to stimulate respiration. Digi- 
talis preceded by ether, ammonia, 
brandy, or whiskey. Prone position, 
feet begin elevated, 193, 194 



INDEX OF DISEASES AND REMEDIES 



1027 



Chloroform. 

Artificial respiration, ether and hot brandy 
hypodermically. Poles of battery with 
rapidly interrupted current swept over 
body, not over diaphragm or phrenic 
nerve. Place patient with head down- , 
ward. Compression of the abdomen : 
and limbs; compression and massage of 
the precordium. Atropine, strychnine, 
and digitalis to stimulate the heart and 
respiration. Laborde's lingual traction, 
214 

Cocaine. 

Ammonia, coffee, strychnine, ether, and 
alcohol. If convulsive in type, treat 
same as Strychnine-poisoning, 238 

Colchicum. 

Tannic acid, emetics, and stomach-pump. 
Opium to relieve pain and oils. Atro- 
pine and stimulants if collapse comes 
on, 243 

Conium. 

Emetics or stomach-pump, strychnine as 
a nervous and respiratory stimulant, 
external heat, and cardiac stimulants, 
if circulation fails, 247 

Copper. 

Yellow prussiate of potassium, sweet oil, 
white of egg; followed instantly by 
emetics or stomach-pump. If emesis or 
purgation is present, emetics are contra- 
indicated; instead, mustard plaster over 
abdomen, and opium internally, are 
often employed, 249 

Corrosive Sublimate. 

Large amounts of white of egg, followed 
by stomach-pump, external heat, stimu- 
lants, 372 

Croton Oil. 

Treatment same as forGastro-enteritis, 255 



Digitalis. 

Tannic acid as a chemical antidote, emetics 
or stomach-pump, external heat to 
abdomen, and aconite as a physiological 
antidote. Maintain horizontal position, 
263 

Elaterium. 

Treatment same as forGastro-enteritis, 268 

Ether. 

Artificial respiration, lowering head if face 
is pale; strychnine, atropine, and digi- 
talis hypodermically, or intravenous in- 
jection of ammonia to stimulate heart 
and respiration; friction and hot applica- 
tions; ether dashed on chest and abdo- 
men; Laborde's method of traction of 
the tongue, 276 

Eucaine. 

Treatment like that of Cocaine intoxica- 
tion, 288 

Formaldehyde. 

Ammonia water, chemical antidote; wash 
out stomach, soothing drinks, morphine 
for pain, 293 



Gelsemium. 

Emetics and stomach-pump, digitalis, 
atropine, and ammonia as cardiac stim- 
ulants; external heat, strychnine, and 
atropine for respiratory center, 296 

Iodine. 

Emetics or stomach-pump, large amounts 
of starch, hot applications, and hypo- 
dermic injections of alcohol, ammonia, 
atropine, digitalis, or strychnine, 325 

Iodoform. 

Sodium bicarbonate to combine with 
iodine, alcohol, diuretics, and hot 
blankets; saline transfusion, 330 

Lead (Acute). 

Epsom or Glauber salts, in large amounts; 
alum; emetics or stomach-pump. Hot 
applications and opium to relieve pain, 
348 

Lead (Chronic). 

Jalap and calomel with opium or alum, 
gr. 2 (0.12), in full dose, valuable in lead 
colic. Blister to back of neck, revulsives 
and pilocarpine in cerebral inflamma- 
tion. Iodide of potassium to eliminate 
lead. Strychnine in progressive paraly- 
sis. Electricity and baths of sulphuret 
of potassium, 351 

Mineral Acids. 

Alkalies, such as magnesium, lime, white- 
wash, and soap as antidotes; white of 
egg, external heat, oils, and opium, to 
relieve irritation. 

Monsel's Solution. 



! Soap, 342 

Nitrate of Silver (Acute). 
Common salt as the chemical antidote, 
opium and oils to allay irritation; also 
large amounts of milk and soap and 
water; maintain bodily heat, 391 

Nitrate of Silver (Chronic). 

Iodide of potassium, to aid in eliminating 
poison, 391 

Nux Vomica and Its Alkaloids. 

Inhalations of amyl nitrite, to prevent con- 
vulsive tendencies; at the same time use 
stomach-pump. Tannic acid followed 
by physiological antidotes, potassium, 
bromide, gr. 60 (2.0), with chloral, gr. 
20 (1.3). If convulsions prevent swal- 
lowing, chloroform patient carefully and 
give antidotes by rectum in starch- 
water. Amyl nitrite, hypodermically, if 
relaxation does not occur, 408 

Opium (Acute). 
Emetics, or stomach-pump, tannic acid, 
black coffee, electricity, and other meas- 
ures to keep patient awake. Atropine 
or strychnine, hypodermically, if respi- 
ration fails. Alcohol, ammonia, and ex- 
ternal heat. Artificial respiration may 
be necessary; repeated washing out of 
stomach. Permanganate of potassium, 
411 



1028 



INDEX OF DISEASES AND REMEDIES 



Opium (Chronic). 

Decrease a sixth or fourth of customary 
amount each twenty-four hours. Co- 
caine not advisable as a substitute, as 
the cocaine-habit may be established. 
Digitalis and strychnine if heart fails. 
Hyoscine hydrobromide in large doses 
very valuable, 413 

Phosphorus. 

Permanganate of potassium, 1 per cent, 
solution, or peroxide of hydrogen. Sul- 
phate of copper is too poisonous in itself, 
437 

Physostigma. 

Atropine as a physiological antidote, ex- 
ternal heat, and cardiac and respiratory 
stimulants, 440 

Scammony. 

Treatment same as f or Gastro-enteritis, 478 

Strychnine. (See Nux Vomica.) 

POLIOMYELITIS. 

Antipoliomyelitis serum, 554 
Urotropin as a prophylactic, 306 

POST-PARTUM HEMORRHAGE, 828 

Adrenalin chloride, 828 
Auto-transfusion, or actual transfusion of 

weak salt solution, necessary in some 

cases, 910 
Beef-tea, \ pint (240.0), and morphine, gr. 

\ (0.008), hypodermically, after reaction 

is established, 910 
Correction of displacement sometimes 

necessary, 908 
Drugs have been recommended, but are 

dangerous as local applications, 909 
Ergot, as a cure and prophylactic, 270, 828, 

909 
Gauze, preferably iodoform, packed into 

uterine cavity, 909 
Ice, used externally and internally, 909 
Manipulations of the uterus, 909 
Method to pursue when caused by hema- 
toma, 909 
Pituitrin, 15 minims, hypodermically, 828 
Suture, if due to laceration, 909 



PROSTATORRHEA. 

Cantharides, 184 

PRURIGO. 

Cantharides, 184 

PRURITUS, 901 

Alum solution in pruritus vulvae, 91 
Arsenic, quinine, bitter tonics, cod-liver 
oil, alkaline diuretics or mineral waters, 
in debility, and avoidance of condiments 
if mouth of vagina or urethra is affected, 
122, 901 
Boric acid, 155 

Brewers' yeast, 1 tablespoonful to a quart 
of water, may be used on a compress in 
diabetic pruritus vulvae, 902 
i Calomel and lard (1 dram to the ounce 

[4.0 : 30.0]), lcoally applied, 378 
j Chloride of calcium, prescription for, 171 
; Chloroform may be used, 902 
Cocaine, relieves temporarily, 902 
Conium ointment in pruritus ani, 247 
Goulard's extract, dilute, useful in pruritus 

pudendi, 353 
Hydrastis, 2 ounces of fluidextract, in- 
jected into rectum, may be advanta- 
geous, 902 
Hydrocyanic acid, locally applied, 314 
Ivory plug for, 902 

Lead-water useful in pruritus pudendi, 353 
Linseed-meal baths, or bran baths, when 

skin is irritated, 903 
Phenol, 887; prescriptions for, 434 
Prescriptions for lotions and ointment, 902 
Salicylic acid, prescription for, 471 
Silver nitrate (gr. 20 to the ounce [1.3 : 
30.0]), locally applied, preceded by 
cocaine, if itching is intense; a 4- to 6- 
grain (0.25-0.4) solution may relieve 
itching of pruritus pudendi, ani, and 
vulvae, 393, 902 
Sodium bicarbonate or borax (1 dram to 

the pint [4.0-480.0]), as a wash, 901 
Sodium thiosulphate, gr. 30 to the ounce 

(2.0-30.0), locally, 490 
Turkish baths, 902 



PRIAPISM. 



Hops, 309 



PSEUDOLEUKEMIA. 

Arsenic internally, and injections of Fow- 
solution into glands, 



ler' 



122 



PSORIASIS. 



371 



PROLAPSUS ANI AND RECTI. 

Quercus, infusion, 462 

PROSTATITIS, 801 

Local treatment to prostatic urethra, and 
use of cold steel sounds in chronic types, 
802 

Perineal incision, to evacuate pus, if 
abscess forms, 802 

Rest in bed, regulation of bowels, leeches 
to perineum, medication to render urine 
alkaline and morphine hypodermically, 
or in suppository, 801 

Soft catheter, allowed to remain in blad- 
der, if retention of urine is persistent, 
802 



Ammoniated mercury in, 

Anthrarobin, 102 

Aristol, 516 

Arsenic, 122 

Cantharides, 184 

Chrysarobin, gr. f (0.008) internally, or 

the ointment with benzoated lard (1 to 4 

or 5), locally applied, face excepted; 

prescription for application, 218, 219 
Gallic acid, ointment, 293 
Pyrogallol, 30 grains to ounce (2.0 : 30.0) 

of lard, 461 
Resorcinol, prescription for, 463 
Tar, locally applied, 509 
Thymol iodide, 516 
Thyroid gland, 517 



PTYALISM. 

Alum, applied on swab, 
ptyalism, 91 



in mercurial 



INDEX OF DISEASES AND REMEDIES 



1029 



Belladonna in idiopathic or mercurial RELAPSING FEVER. 

types, 14/ Arsphenamine (salvarsan), a specific, 130 



PUERPERAL DISEASE, 903 

(For treatment see special titles.) 

PUERPERAL FEVER, 903 

Antipyretics, best abstained from as long 
as possible, 904 

Antistreptococcic serum, streptococcic 
vaccines, and injections of normal salt 
solution, important adjuvants, 554, 904 

Argyrol, 25 per cent., or 5 per cent, emul- 
sion of silver iodide, a 1 per cent, solu- 
tion of hegonon or a 5 per cent, solution 
of silvol injection into bladder after 
irrigation, 906 

Bier's cups, 907 

Boric acid or oxycyanide of mercury ( 1 : 
5000) solution, as injections into blad- 
der, to prevent septic cystitis, 906 

Curette or placental forceps, to remove 
membranes if fever continues after anti- 
septic injections, 904 

Epsom salt, concentrated solution, 2 
drams (8.0) every fifteen minutes, if 
peritonitis develops, 905 

Hot fomentations, or ice-bag, and later 
compresses dipped in lead-water and 
alcohol, or saturated solution of mag- 
nesium sulphate, 907 

Iodoform (5 grain) suppositories and boric 
acid irrigations in septic proctitis follow- 
ing, 906 

Laparotomy, occasionally saves life, if 
septic peritonitis develops, 905 

Lugol's solution, 2 drams to the quart, 
as uterine douche, 904 

Nutriment in large amounts and alcoholic 
stimulants, if symptoms of systemic in- 
vasion arise, 904 

Salol and urotropin if renal infection 
ensues, 906 

Silver nitrate (gr. 40 to 60 to the ounce 
[2.60-4.0 : 30.0]), locally applied to un- 
healthy ulcerated wounds; 905 

Vaccines useful, 904 

PULMONARY EDEMA. 

Adrenalin solution, 10 to 15 minims intra- 
muscularly, may be used with advan- 
tage, 504 

Atropine in large dose, is the best remedy 
we have, 148 

PURPURA HEMORRHAGICA. 

Turpentine, 527 

PYELITIS. 

Buchu in chronic types, 165 

Cantharides, 183 

Copaiba, useful in subacute stage, 248 

Juniper, as a tonic in chronic types, 345 

Pariera, 426 

Urotropin, 306 

Uva ursi, 528 

QUINSY. 

Aconite, in early stage, 75 

Salicylic acid, gr. 3 (0.2) hourly, acts as 
a specific, especially if due to rheuma- 
tism, 470 



REMITTENT FEVER, 853 

Calomel will often relieve vomiting, 370 

Cool sponging with friction if fever is ex- 
cessive, 853 

Eupatorium, 289 

Morphine, spirit of chloroform, or aconite, 
in sthenic cases, to control vomiting, 853 

Quinine, gr. 20 to 30 (1.3-2.0), preceded 
by calomel, gr. 3 to 4 (0.2-0.25); if not 
retained, administer by rectum, or hypo- 
dermically, Avith divided doses of Seid- 
litz powder by mouth, 224, 853 

Tonics, potassium salts, to regulate kid- 
neys and purgatives if necessary, during 
convalescence, 854 

Turpentine stupe, if belly is tender, 853 

RETINITIS, 914 

Atropine, dark glasses, and later suitable 
lenses, if due to eye-strain, 915 

RHEUMATISM, ACUTE (ARTICU- 
LAR), 915 

Acetanilide relieves pain and fever, 69, 917 
Acetate of potassium, 453, 918 
Ammonium bromide and phosphate, 97 
Antipyrine, gr. 5 to 10 (0.3-0.6), or anti- 

febrin, gr. 4 to 8 (0.25-0.5), often very 

valuable, 110 
Aspirin in acute cases, 141 
Benzoic acid, drams 2 to 3 (8.0-12.0) 

daily, said to be specific, 150 
Bicarbonate or citrate of potassium, gr. 20 

to 30 (1.3—2.0), in water, every five hours 

in obstinate cases, 918 
Bicarbonate of sodium, 469, 915, 916 
Blisters over joints, useful after systemic 

disturbance is past, 918 
| Caffeine useful to support the heart, 917 
! Camphor liniment, 178 
Capsicum plaster, 185 
Cimicifuga, shortens attack and relieves 

pain in some cases, 219, 917 
Colchicum, prescription for, 243, 918 
Fuller's lotion applied on hot cloths to 

joints, 915 
Guaiac, 301 
| Hot baths useful, 623 
Ice-cold compress, may relieve inflamed 

joints, 915 
Ichthyol, ointment, valuable, applied to 

joints, prescription for, 319, 915, 918 
Iodine, ointment or tincture, painted over 

parts, 918 
Leeches, over precordium in endocarditis, 

during, 918 
Lemon-juice or lime-juice, or citric acid, 

beneficial in nearly all cases, 231, 904 
Magnesium, sulphate solution locally to 

relieve pain, 361, 915 
Morphine in endocarditis, 918 
Xovaspirin, 403 
Oil of gaultheria, useful as a substitute for 

salicylic acid; also used as a local appli- 
cation to the joints, 295 
Oleum succini, applied locally over joints, 

92 
Phenacetin, alone or with salol, 72, 917 
Phylacogen, specific in its effects in some 

cases, 628, 917 



1030 



INDEX OF DISEASES AND REMEDIES 



Potassium iodide, useful in subacute or 
obstinate types, prescription, 322, 917 

Potassium nitrate, 458 

Salicin used in place of salicylic acid, 467 

Salicylic acid, gr. 20 (1.3) thrice daily; if 
untoward symptoms arise, it must be 
stopped, 469, 916; applied to joints in a 
salve when stomach is irritable, 471, 916 

Salol (phenyl salicylate), useful as a sub- 
stitute for salicylic acid; dangerous in 
large doses, 474 

Sodium bicarbonate (gr. 20 to the ounce 
[1.3 : 30.0]), to inflamed joints, 487, 915 

Splints for fixation of limbs, may relieve 
greatly, 915 

Strontium salicylate useful when other 
drugs are not well borne, 495, 917 

Vaccine therapy, 916 

Veratrine ointment, used locally, applied 
to joints, 530, 918 

RHEUMATISM (CHRONIC), 919 

Arsenic, useful in some cases, 123 

Cimicifuga, sometimes relieves, 219 

Citric acid, 231 

Cod-liver oil, internally; also useful rubbed 
into joints, 240, 919 

Colchicum, with iodide of potassium, pre- 
scription for, 242, 919 

Hot-air bath, 599 

Ichthyol, the best remedy for joints, 920 

Iodine, locally applied, 327 

Liniments, prescription for, 920 

Ointments, prescription for, 920 

Potassium iodide, colchicum, and sarsa- 
parilla, usually indicated; see Prescrip- 
tions, 322, 919 

Salophen, 475 

Sulphur, 500 

Turkish or Russian baths very valuable, 
592, 919 

Veratrine ointment, gives greatest relief in 
some cases, prescription for, 530, 920 

RHEUMATISM (GONORRHEAL). 

Antigonococcic serum in, 551 
Phylacogens, 628 

RHEUMATISM (MUSCULAR). 

Acetanilide in subacute, 69 

Ammonium benzoate useful in certain 

cases, 96 
Burgundy pitch, a mild local remedy, 448 
Croton-oil ointment, 255 
Dover's powder in conjunction with hot 

drinks and hot foot-baths, often cures, 

416, 417 
Mustard as a counterirritant, 387 
Neocinchophen useful, 390 
Novaspirin, 403 

Oil of cloves in liniment, locally, 232 
Pitch, locally, 448 
Salicin useful as a substitute for salicylic 

acid, 467 
Salol useful, 474 
Veratrine ointment, locally applied, 530 

RHINITIS. 

Creolin (1 : 1000), as a nasal douche, 251 
Dobell's solution as a wash, 155 
Fluid petrolatum, in spray, 430 
Pituitrin, diluted from three to ten times 

with normal salt solution, used locally, 

450 



Potassium permanganate, 
fetid rhinitis, 430 



solution, 



RHUS POISONING. 

Aluminum acetate useful, 92 

Ammonium chloride, 99 

Grindelia, 301 

Infusion of lobelia, 357 

Lead acetate, 351 

Liquor plumbi subacetatis, 352 

RICKETS, 921 

Arsenite of copper, 921 

Cinchona or strychnine, 921 

Cod-liver oil, prescription for, 240, 921 

Cool sponging or rubbing with salt and 
whisky (1 dram to the pint [4.0 : 
480.0]), useful at night, 922 

Hypophosphites and lactophosphates use- 
ful, 172 

Iodide of iron, syrup of, if scrofulous ten- 
dency or anemia exists, prescription for. 
921 

Lecithin, as a tonic, 353 

Lime salts, as bone tonics, 921 

Massage and passive movements, 922 

Mineral acids, physostigma and simple 
bitters, as digestive tonics, 921 

Nux vomica, rarely given because of bitter- 
ness, 921 

Phosphorus, gr. T J-<y (0.0006), in sugar- 
coated pill, 439, 907 

Quinine, cod-liver oil, nux vomica, and 
iron as general tonics, 921 

Sodium and lime salts, useful in nursing 
and pregnant women, 921, 922 

Sodium phosphate to regulate the bowels, 
489 

Vitamines, 532, 921 

RINGWORM (See Tinea Circinata.) 

SATYRIASIS. 

Potassium bromide, one of the best reme- 
dies, 160 

SCABIES. 

Sulphur, the best remedy, 500 

SCARLET FEVER, 922 

Aconite, harmful if constantly employed, 75 

Antidiphtheritic serum, when false mem- 
brane forms in throat, 924 

Antipyrine or acetanilide may produce col- 
lapse in large doses, 110 

Antistreptococcic serum, 554 

Benzoated lard, or almond oil, useful 
locally applied, to allay itching, 925 

Bromide of sodium, with chloral, useful 
when convulsion ushers in attack, 923 

Chlorate of potassium, locally applied by 
spray or swab, in sore throat, 924 

Cold sponging, useful, 923 

Diet, 923 

Dry cups, 923 

Hot packs, 923, 924 

Hydrogen peroxide to throat if a mem- 
brane is present, 924 

Ice applied externally and held in mouth, 
to prevent swelling of throat, 924 _ 

Ice-bag or rubber head-coil to head, if very 
hot, 924 



INDEX OF DISEASES AND REMEDIES 



1031 



Juniper, in later stages, if there is renal 

atony, 345 
Potassium citrate and sweet spirit of nitre, 

prescription for, 923 
Potassium permanganate (gr. 20 to pint 1 

[1.3 : 480.0]), as a gargle, 430 
Streptococcus vaccine in, 642 
Strychnine, iron, simple bitters, quinine, or 

Basham's mixture, in convalescence, 925 
Sweating, necessary in nephritis, 925 
Warm wet pack, useful to bring out rash, 

923, 924 
Water, pure, such as Vichy or Poland, in 

large amounts, 923 

SCIATICA, 925 

Absolute rest of limb in splints very need- 
ful, 926 

Acetanilide and antipyrine, 69, 925 

Acupuncture, recommended, 537 

Chloroform, deeply injected over exit of 
nerve, a favorable remedy, 213 

Cod-liver oil, of service in obstinate cases, 
240, 926 

Cold applications, 562 

Ether or rhigolene sprayed on part, often 
effective, 926 

Hot-water bags, placed around exit of 
sciatic nerve, 926 

Liniments for rheumatism, may be tried, 
926 

Methylene blue, gr. 5, twice or thrice a 
day to relieve pain, 925 

Opium subcutaneously over affected part, 
415 

Potassium bitartrate or citrate, gr. 40 (2.6) 
thrice daily, in plenty of water, to regu- 
late kidneys, 925 

Potassium iodide, 322 

Remedies for rheumatism often relieve, 911 

Salicylic acid, 470 

Sulphur, 500 

Wet or dry cups, highly beneficial over 
course of nerve, 926 

SCLERITIS, 778 

Atropine, boric acid and hot-water com- 
presses, in early stages, 778 

Eserine, with pilocarpine sweats or cau- 
tery, in stubborn episcleritis without 
iritis, 778 

Specific treatment, in syphilitic cases, 778 

Yellow-oxide ointment, associated with 
massage to subdue infiltration, 778 

SCLEROSIS. 

Antipyrine, 111 
Nitrate of silver, 392 

SCROFULOSIS, 926 

Arsenic or corrosive sublimate, useful if 
anemia is present, prescriptions for, 926 

Cod-liver oil, the best remedy, 240, 926 

Diet and exercise, 926 

Excision, or scraping gland, and packing 
with iodoform gauze if other treatment 
fail, 927 

Hypophosphite of calcium, 172 

Ichthyol ointment, useful, rubbed into per- 
sistent enlargements, prescription for, 927 

Iodine ointment and lard, equal parts, 
rubbed into glands, stopping at first 
sign of reddening or fluctuation, 326, 927 



Iron, syrup of the iodide, in anemia, pre- 
scription for, 341, 926 
! Phosphate of sodium or lime, if glands are 
breaking down, 172 

Sulphurate of calcium, if suppuration is 
active, 927 

SCURVY, 927 

Arsenic and iron, of service in most cases, 

927 
Beef juice, 927 
Citric acid has been used but lemon juice 

is better, 231 
Diet, 927 
Lemon-juice or orange-juice, particularly 

indicated, 231 
Lime juice, 927 
Tomato juice, 927 
Vitamines, 532 

SEA-SICKNESS. 

Bromides, the best prophylactics, 160 
Chloral-formamide and potassium bro- 
mide, 197 
Chloretone valuable, 197 
Nitrite of amyl, 102 

SEBORRHEA CAPITIS. 

Resorcinol valuable; prescription for, 463 

SHOCK, 928 

Acacia solutions intravenously, 65, 928 
Adrenalin chloride solution 1 : 1000, \ 
dram in 1 pint of hot normal saline 
solution injected into a vein, 505 
Alcohol, 80 

Alkaline injections, 928 
Atrophine in full dose, intramuscularly, 
with hot applications, very useful in 
first or second stage, 148, 928 
Caffeine valuable, 928 

Digitalis, valuable as an adjuvant to atro- 
pine, 262, 929 
Gum acacia in normal saline solution by 

intravenous injection, 615 
Heat, external, very useful, 929 
Hypodermoclysis, useful, 601, 928 
Intravenous saline injections, 615; also 

salines by Murphy drip, 929 
Pituitrin useful in surgical shock, 450 
Strychnine, very valuable, 406, 928 
Transfusion with whole blood if hemor- 
rhage has been a factor, 928 

SINUSES. 

Bismuth subcarbonate with petrolatum, 
33 per cent., by injection, in tubercular 
and other sinuses, 154 

Chalk as substitute for bismuth, 170 

SKIN DISEASES. 

Arsenate of iron, 338 
| Arsenic, in dry, scaly types, 122 
Bismuth subgallate, when there is much 

secretion, 153 
I Chrysarobin locally in parasitic disease, 218 
i Cod-liver oil, in strumous types, 240 
j Copper sulphate, gr. r } 6 (0.006) thrice 
daily, if arsenic is not well borne, 250 
I Corrosive sublimate, oz. ^ (1.6), and am- 
monium chloride, oz. 1 (30.0), useful 
added to bath, in syphiloderm, 374 



1032 



INDEX OF DISEASES AND REMEDIES 



Hot mineral springs, in chronic skin dis- 
eases, 623 

Hydrocyanic acid, in itching types, pre- 
scription for, 314 

Ichthyol in those forms associated with 
atony and induration of the deeper 
layers, 319 

Ointment of biniodide and of yellow oxide 
and lard, in equal parts, useful applica- 
tion, 374, 381 

Opium allays nervous irritation caused by 
itching skin diseases, 416 

Petrolatum, as an emolient dressing, 430 

Pyrogallol in parasitic skin diseases, 461 

Sodium thiosulphate in pityriasis versi- 
color, 490 

Tar ointment, and prescriptions containing 
it, locally applied except on face, 510 

Unguentum hydrargyri ammoniati, 371 

Zinc oxide ointment, 534 

SMALLPOX, 929 

Antipyrine or acetanilide to control head- 
ache and backache, 110, 929 
Brandy and whisky, if pulse fails, 929 
Bromides and chloral, in insomnia; latter 

must be used carefully, 929 
Chlorate of potassium with tincture of 

myrrh, as a mouth-wash, 930 
Disinfection and hygiene necessary, 930 
Flexible collodion, glycerite of starch, or 

simple cerate, locally applied, to prevent 

itching, 930 
Iron, tincture of the chloride, to give 

strength, and act as a specific, 929 
Mustard plasters contraindicated, 929 
Opium for restlessness caused by itching, 

416 
Phenol and sweet oil (1 : 100), as an oint- 
ment to check irritation, 930 
Phenol, pure, touched to the vesicles to 

decrease pustulation, secondary fever, 

and pitting, 434 
Salicylic acid and vaseline, or cold cream 

(4 : 100), best local application, 930 
Silver nitrate, locally applied, to prevent 

pitting, 392, 930 
Spirit of nitre and spirit of Mindererus to 

allay fever, 929 

SORDES. 

Glycerin and water, equal parts, useful as 
a mouth-wash, 299 

SORE THROAT. 

Aconite, in early stage, 75 

Alum (gr. 20 to the ounce [1.3 : 30.0]), 

locally applied on swab, 91 
Arsenic, 123 
Belladonna of greatest service in some 

cases, 148 
Capsicum, tincture of, and glycerin, 185 
Copper sulphate (gr. 4 to the ounce [0.25 : 

30.0]), often of service in relaxed sore 

throat, 250 
Ethylhydrocuprein hydrochloride, \ grain 

(0.03) to the pint of a 1 to 1500 solution 

of thympl, is efficient as a gargle in pneu- 

mococcus sore throat, 287 
Gambir, as a gargle or in troches, 294 
Guaiac, 301 

Hamamelis in relaxed sore throat, 304 
Iodine in gargle in relaxed sore throat, 329 



Kino, as a gargle, 346 

Lysol in 1 per cent, solution as a gargle in 
septic sore throat, 358 

Myrrh, tincture of, diluted one-half, as a 
gargle, in ulcerated types, 388 

Phenol (1 : 100), in spray, in ulcerated 
types, 433 

Potassium chlorate gargle in anginose 
form, prescription for, 455 

Quercus, useful as a gargle, 462 

Rhus glabra, with glycerin and water, use- 
ful as a gargle, 465 

Salol useful in chronic sore throat due to 
lithemic diathesis, 474 

Troches of morphine and ipecac, 336 

SORES. 

Acetic acid, in old sores, 70 

Black wash, useful for syphilitic sores, 375 

Camphor, locally applied as a stimulant in 
indolent sores, 178 

Charcoal, applied to old sores as a deodor- 
ant and antiseptic, 186 

Cold cream, as an emollient dressing, 466 

Dried alum a useful dressing, 91 

Formaldehyde solution useful for cauter- 
izing syphilitic sores, 292 

Gallic acid, 293 

Iodoform, gr. 20 (1.3), with oil of eucalyp- 
tus, oz. \ (16.0), or iodoform, oz. £ (16.0) 
camphor, gr. 75 (5.0), and essence of 
roses, gtt. 2 (0.1), as a dressing for syph- 
ilitic sores, 331 

Lactic acid bacilli used locally on septic 
wounds or in sinuses, 347 

Petrolatum, as an emollient dressing, 430 

Phenolsulphonates of sodium and zinc as 
mild antiseptic stimulants, 436 

Potassium permanganate (gr. 60 to the 
pint [4.0 : 480.0]), as a wash, 430 

Quercus, powdered as a poultice, to check 
discharge, 462 

Red or yellow oxide of mercury a good 
dressing for syphilitic sores, 380 

Salicylic acid as a salve or dusting-powder 
in venereal sores, 472 

Sulphuric acid, sometimes used as an 
escharotic in venereal sores, 502 

Zinc oxide ointment, 535 

SPASMS. 

Belladonna, useful in urethral, anal and 

vesical spasm, 147 
Benzyl benzoate useful in spasm of un- 

striped muscle, 151 
Bromides in spasmodic contractions, 159 
Cannabis, useful in vesical spasm, "181 
Conium, useful, if due to irritation of 

nerve-trunk, 246 
Ether, inhalation, relieves local spasms, 282 
Gelsemium in localized muscular spasms, 

296 
Hot pack, to relax, 596 
Hyoscyamus in local spasm or when pain 

is due to spasm, 316 
Nitrite of amyl, of service to relax, 101 



SPERMATORRHEA. (See Emissions.) 
SPRAINS. 



Arnica, 117 

Camphor liniment, 178 



INDEX OF DISEASES AND REMEDIES 



1033 



Cold applications, useful in sprained ankle, 

561 
Oroton oil liniment, 255 
Hot-air bath, 590 

Hot bath, very useful in sprained ankle, 590 
Ichthyol ointment, well rubbed in, very 

useful, 319 
Lead-water and laudanum, 352, 417 
Leeches for relief of swelling, 619 
Soap liniment, 485 
Soap plaster, used as a support to sprained 

joints, 486 
Soluble glass, 483 
Turpentine liniment, 528 
Warming plaster, 448 



STINGS AND BITES, 930 

Ammonia or alkaline liquids, locally ap- 
plied to neutralize poison, 95, 930 

Antivenine, 931 

Corrosive sublimate, with flexible collodion 
(1 : 100), painted over part; salicylic 
acid a useful addition, 930 

Hydrogen peroxide applied locally to 
hornet's sting, of great value, 315 

Ipecac paste for stings of bees, 336 

Ligature, or cleansing of wound, at once, 
to prevent absorption in snake-bite, 930 

Oil of citronella in mosquito-bites, 930 

Phenol (1 : 50 or 100), sponged over part 
useful in mosquito-bites, 930 

Potassium permanganate, applied and in- 
jected around snake-bite, followed by 
alcohol in full dose, 430, 930 

Vinegar, dilute or pure, locally applied, 
often relieves insect-bites, 930 



STOMATITIS, 931 

Borax, as a mouth-wash, prescription for, 

155, 931 
Bromide of potassium or sodium, gr. 1 to 

10 (0.06-0.6) thrice daily, when nervous 

irritability is excessive, 932 
Cleansing nipples, in breast-fed babies, 932 
Cocaine, before cauterization, 235 
Mel boracis, 157, 309 
Nitrate of silver, stick touched to sore 

spots when they fail to yield to other 

treatment, 393, 931 
Nitric acid, 1U 3 (0.2), in water, taken 

through tube, 394 
Nitro-muriatic acid, indicated when hepa- 
tic torpor exists, 931 
Peroxide of hydrogen, 931 
Phenol as a mouth-wash, 433 
Potassium chlorate, prescription for, 455, 

931 
Prescription for stomatitis associated with 

pyorrhea alveolaris, 931 
Salicylic acid (1 : 250), as a mouth-wash, 

after blisters have broken, to allay pain, 

471 
Salines or rhubarb, if constipation exist, 931 
Sweet spirit of nitre, T([ 10 (0.6), well 

diluted, to a one- or two-year-old child, 

and a warm foot-bath before retiring, 

to produce rest, 932 
Thymol, prescription for, 515 
Tonics and careful diet after the attack, 932 



STYES, 932 

Bpric acid (saturated solution), collodion 
(ethereal solution), or red or yellow 
oxide of mercury salve (gr. 2 to the 
ounce [0.12 : 30.0]), locally applied to 
abort, 932 
Calx sulphurata, if they tend to return, 932 
Collodion, 932 

Hot compresses, to alleviate pain, 932 
Incision, as soon as pus forms, 932 
Tonics, if general health is poor, 932 
VaGcines, excellent in stubborn cases, 932 
Yellow mercuric oxide ointment, 381, 932 

SUBINVOLUTION OF UTERUS. 

(See Involution, Anomalies of.) 

SUNBURN. 

Almonds, in emulsion, 88 

Carbonate of lead, prescription for, 352 

SUNSTROKE, 932 

Antipyrectics, almost useless, 110, 933 

Hot baths ( 1 5 ° to 1 1 ° F.) , or hot bottles 
or bricks, in heat exhaustion, 934 

Ice, application to chest, back and abdo- 
men, as quickly as possible, in thermic 
fever, 933 

Intravenous injections of normal salines, 
933 

Salicylic acid, quinine, and similar drugs 
contraindicated, 933 

Tonics, during convalescence in heat ex- 
haustion, 934 

Venesection, best treatment if face be 
cyanotic and heart laboring, and if men- 
ingitis threatens after thermic fever, 
654, 933 

Veratrum may be used if meningitis 
threatens, 933 

SUPPRESSION OF URINE. 

Sparteine useful, 480 

SYNCOPE. 

Ammonia, if due to shock or indigestion, 94 

SYNOVITIS. 

Counterirritation, 579 
Iodine, 327 

Phenol (2 per cent, strength), as an injec- 
tion in chronic types, 434 

SYPHILIS, 934 

Arsphenamine in all stages, 130, 365, 935, 
936 

Bichloride of mercury, hypodermically, 
368, 372, 937 

Biniodide of meicury, 375 

Calomel, hypodermically, 376 

Calomel ointment, 4 drams (15.0) to the 
ounce (30.0), used on penis, as a pro- 
phylactic against syphilis, 378 

Calomelettsin place of blue ointment, 376 

Cod-liver oil, useful in advanced cases, 240 

Formaldehyde solution, useful for cauter- 
izing sores, 292 

Guaiac, not used at present, 301 

Hot baths useful, 623 

Hypodermic injection of mercury, 368, 
372, 375, 376, 378, 381 



1034 



INDEX OF DISEASES AND REMEDIES 



Iodides, followed if necessary by mercury, 
recommended by some, 321, 935, 938 

Iodoform, gr. 1 to 5 (0.05-0.3), internally 
in tertiary stage, and the ointment ap- 
plied to ulcers, very useful, 331 

Iodol, in tertiary stage, 332 

Mercurial ointment, by inunction, 379, 935 

Mercurialized serum in spinal syphilis, 373 

Mercury by fumigation, general and local, 
366, 367, 936, 937, 938 

Mercury with chalk, chiefly employed in 
infantile syphilis, 379 

Neoarsphenamine (neosalvarsan) , 389/938 

Ointments and washes of mercury, and hot 
applications, 368, 937 

Protoiodide of mercury, 381, 937 

Salicylate of mercury, hypodermically, 
368, 937 

Salvarsan, in all stages, 130, 365, 935, 936 

Sarsaparilla, a useful adjunct to potassium 
iodide, 477 

Sodium cacodylate, gr. 1 to 4 (0.06-0.25), 
by intramuscular injection every third 
or fourth day, 487 

Sodium iodide by mouth or intravenously, 
489 

Stillingia, used as an aid to other drugs, 
494 

Vapor baths, hypodermic injections, or 
inunctions, useful modes of applying 
mercury if it cannot be taken by mouth, 
624, 937 

SYSTEMATIC STRAIN. 

Opium, useful in prolonged physical strain, 

417 
Quinine, gr. 2 to 4 (0.12-0.25), useful to 

prevent exhaustion following physical 

and mental strain, 225 

TABES DORSALIS. (See Locomotor 
Ataxia.) 

Chloral formamide, prescription for, 197 
TAPE-WORM. (See Worms.) 

TEETHING. 

Bromide of potassium, to prevent convul- 
sions, 160 

TETANUS, 939. (See Poisoning 
from Strychnine.) 

Amyl nitrite, to relieve and prevent, 101 

Antitoxin, value of, depends upon how 
early it is given, 554, 939 

Chloral and bromide of potassium, by 
mouth or rectum, 195 

Chloretone an efficient palliative, 197 

Hot pack may be used, 596 

Iodine solution, 3 per cent., swabbed on 
point of infection, 939 

Magnesium sulphate solution, injected in- 
traspinally, materially aids in control- 
ling spasms, 361 

Physostigma, of moderate value, 441 

TETANY. 

Calcium salts recommended in tetany due 
to disease of injury of parathyroid glands 
and for tetany of lactation and preg- 
nancy, 172 

Parathyroid gland, 426 



TINEA CAPITAS. 

Lime-water, locally applied, 174 

TINEA CIRCINATA, 922 

Borax, strong solution, locally applied, 155 
Iodine, applied with camel-hair brush, 327 

922 
Turpentine, useful, applied, with a brush, 

527 

TINEA TARSI. 

Copper, crystals, or weak solution, applied 
to diseased eyelid, 250 

TINEA TONSURANS. 

Anthrarobin as a wash, 102 
Borax, strong solution, locally applied, 155 
Iodine, applied with camel-hair brush, 327 
Oil of cajuput, applied pure, 169 

TOE-NAILS (INGROWING). 

Absorbent cotton, soaked in strong alum 

solution, and inserted under nail, 91 
Liquor potassi hydroxidi, to soften nail 

prior to packing with cotton or partial 

evulsion, 355 
Phenol to produce local anesthesia in 

eversion, 434 

TONSILLITIS, 939 

Alum stick, deeply applied, 91 
Aspirin, locally in, 141, 940 



Biniodide of mercury, gr. 



(0.0003) 



every hour, in water, for four or five 

hours, to abort, 375, 940 
Corrosive sublimate, when inflammation is 

severe, 374 
Glycerin and tincture of capsicum, equal 

parts, applied by swab, 185 
Guaiac, 301 

Guaiacol, applied locally, 302, 940 
Hot fomentations and gargles useful in 

some cases, 940 
Hydrogen peroxide (2 per cent, strength), 

in spray, in ulcerative types, 315, 940 
Ice-bag to throat, 940 
Iron, tincture of the chloride, 340, 940 
Monsel's solution, pure, applied with 

camel-hair brush, 342 
Novaspirin, 403 
Phenol, undiluted, useful in early stages, 

435, solution (1 : 100), as an antiseptic 

gargle, 940 
Salicylates are valuable in rheumatic 

cases, 470 
Saline purgative, followed by fever mixture 

of aconite, sweet spirit of nitre, and 

potassium citrate, 939 

TOOTHACHE. 

Chloretone dissolved in oil of cloves, ap- 
plied on cotton, 198 

Creosote, applied on cotton, often relieves, 
253 

Oil of cloves, inserted into cavity on cot- 
ton, 232 

Oil of peppermint, applied on cotton, 427 

TORPOR. 

Acetate of potassium in hepatic torpor, 453 
Ammonium chloride, in hepatic torpor, 99 
Arsenic, in gastric torpor, 123 



INDEX OF DISEASES AND REMEDIES 



1035 



Citric acid, in hepatic torpor, 231 
Euonymus, in mild hepatic torpor, 289 
Nitro-hydrochloric acid, in torpor of liver, 

398 
Pituitrin in postoperative intestinal torpor, 

450 
Russian and Turkish baths, useful in tor- 
pidity of skin and kidneys, 591 
Taraxacum, in hepatic torpor, 510 

TORTICOLLIS. 

Belladonna, injected into muscles, 147 
Gelsemium, 296 
Hot compresses, 591 



TREMOR. 



Hyoscine, 317 
Sparteine, 480 



TRYPANOSOMIASIS. 

Arsphenamine (salvarsan) is a specific, 130 
TUBERCULOSIS, 940 

Acetanilide, generally acts unfavorably, 68 

Agaracin, of doubtful value in night- 
sweats, 77 

Almonds, essential oil of, recommended in 
cough, 88 

Alum (gr. 10 to 20 to the ounce [0.6-1.3 : 
30.0]), or sulphuric acid (1 dram to 
the pint [4.0 : 480.0]), useful, sponge over 
body in night-sweats, 944 

Antipyrine, harmful, 110 

Arsenic, in phthisis, and in phthisical ten- 
dencies, 122, 123 

Artificial pneumothorax, 944 

Atropine, gr. T h> to ^ (0.0004-0.0006), 
hypodermically, in excessive night- 
sweats, 944 

Blister, small, useful over new pleuritic 
spots, 944 

Cacodylate of iron in albuminuria of, 339 

Camphor in almond oil hypodermically, in 
sudden depression, 177 

Camphoric acid, gr. 20 to 30 (1.3-2.0), in- 
valuable, 180, 944 

Cannabis, 181, 943 

Chloroform, spirit of, used by inhaler, 
often relieves cough, 943 

Cinnamic acid hypodermically and intra- 
muscularly, 230 

Climatic treatment, 624 

Codeine, recommended in excessive cough, 
238 

Cod-liver oil, rules for its use, 239, 942 

Copper in tubercular tendencies, 250 

Creosotal as an expectorant, 254 

Creosote, internally, in spray or by inhaler; 
often relieves cough and discomfort; 
contraindicated if fever and hemoptysis 
are present; prescription for, 252, 942, 
943 

Glycerin and water, equal parts, with 
lemon-juice, useful as a mouth-wash, 299 

Guaiacol carbonate more readily borne by 
the stomach than guaiacol, 303 

Guaiacol useful in, 302 

Heroin useful to stop cough, 944 

Hygienic measures, 942 

Inhalations of steam from corrosive subli- 
mate solution (1 : 10,000), stopping at 
first sight of mercurial effects, in laryn- 
geal phthisis; precede inhalation with 
cocaine spray (4 per cent, solution), 944 



Iodine useful, painted over new pleuritic 
spots, also useful in chronic cases as an 
inhalant, 326, 327, 944 

Iodoform emulsion (10 per cent.) useful 
in tubercular abscess, 331 

Iodoform with small amount of powdered 
talc and a little morphine, useful when 
puffed into the larynx in laryngeal tuber- 
culosis, 944; also used in spray, 332 

Iodol, of use in tubercular laryngitis, 332 

Lactic acid applications (10 to 60 per cent, 
solution) , in laryngeal tuberculosis, using 
cocaine spray first to relieve pain, 944 

Lactophosphates and hypophosphites, 172 

Lecithin, used when nervous system is 
feeble, 353 

Levulose, as a substitute for sugar in die- 
tetic treatment, 354 

Morphine and wild-cherry bark in cough, 
prescription for, 943 

Oil of cloves, 232 

Opium, may be given in last stage to re- 
lieve pain and discomfort, 417 

Oxygen inhalations in dyspnea, 422 

Phenol 0U 5 to 15 to the ounce [0.3-1.0 : 
30.0]), in spray, 433 

Potassium cyanide, in excessive cough, 
prescription for, 457 

Silver nitrate (gr. £ to 2 to the ounce [0.03- 
0.12 : 30.0]), in spray, may be tried in 
laryngeal types, 392 

Sodium cacodylate, in anemia, 487 

Strychnine, in dyspnea, 406 

Sulphuric acid, internally, may relieve 
night-sweats, 502, 944 

Terebene, iodide of ethyl, and chloroform, 
equal parts, for inhalation, 943 

Thiocol as a substitute for creosote, 513 

Thoracic exercises beneficial in early 
stages, 601 

Tuberculin, 522, 525 

TYPHOID FEVER, 948. (See Fever.) 

Acetanilide, generally acts unfavorably, 68 

Alcohol, useful throughout course of dis- 
ease, 81, 949 

Asafcetida, by rectal injections, in tym- 
panites, 139 

Belladonna, in cases of collapse or vaso- 
motor relaxation, 148 

Calomel, gr. | (0.001) every fifteen min- 
utes, till gr. 1 (0.06) is taken, followed 
by magnesium sulphate, | ounce (16.0), 
if constipation lasts two days, 377, 951 

Camphor in almond oil, hypodermically, 
in sudden depression, 177 

Cascara sagrada, for constipation, 951 

Cold bathing, 566. 574, 952 

Diet, 950, 951 

Enemas, to be tried first, if constipation 
lasts over two days, 951 

Glycerin and water, equal parts, with a 
little lemon-juice, as a mouth-wash, 
299, 951 

Guaiacol carbonate, an intestinal anti- 
septic of value, 303, 951 

Hydrochloric acid, dilute, 1U 5 (0.3) every 
few hours, or if liver is inactive, strong 
nitrohydro chloric acid, TTL 5 (0.3), 312 

Hypodermoclysis, if toxemia is marked, 
952 

Ice-bag over the heart to relieve palpita- 
tion, 562 

Ice rub, 950 



1036 



INDEX OF DISEASES AND REMEDIES 



Liquorice powder, dram 1 (4.0), if con- 
stipation lasts over two days, 951 

Milk diet, 950, 953 

Morphine, only enough to relieve agony, if 
perforation occurs, 952 

Opium, for insomnia, 416 

Phenolsulphonate of zinc, useful, 436 

Phosphorus, if nervous system is affected, 
439 

Prescription for diarrhea, 951 

Quinine inferior to new antipyretics, 225 

Reduction of fever by cold, 566 

Rest and diet, 948, 950 

Silver nitrate, gr. J to J (0.001-0.015), 
highly recommended, 392 

Sodium citrate, in indigestion of milk in 
typhoid fever, 488 

Sponging with tepid water and alcohol, 
with friction, of value when toxemia is 
marked, 950 

Thymol, as an intestinal antiseptic, 515 

Turpentine, in the form of stupes, enemata 
or by mouth, in tympanites, also useful 
in later stage, to relieve diarrhea, heal 
ulcers, and prevent relapse, 526, 527, 951 

Urotropin (hexamethylenamin) to render 
the urine sterile and prevent cholecysti- 
tis, 306, 952. (For remedies for compli- 
cations — intestinal hemorrhage, pneu- 
monia and pleurisy — see their titles). 

Vaccines as prophylactic, 642 



ULCERS. 

Aristol, 516 

Burnt alum, as a dressing for old ulcers, 91 

Castor oil, with a few drops of balsam of 

Peru or oil of eucalyptus, excellent, 190 
Caustic potash, as an escharotic for exu- 
berant ulcers, 457 
Chloretone, with equal parts of boric acid, 

as an antiseptic dressing, 198 
Conium, used locally to relieve pain, 247 
Copper, in solid or powder form, locally 

applied to indolent ulcers, 250 
Creolin, solution (1 : 100), as a douche for 

nasal ulcers, 251 
Dionin as substitute for morphine in ulcer 

of stomach or bowel, 267 
Dried alum, useful, 91 
GaUic acid ointment, in actively discharg- 
ing ulcers, 293 
Hamamelis, locally applied on a cloth, 

relieve leg ulcers, 304 
Hydrogen peroxide, a useful application, 

315 
Lime, as an escharotic in old ulcers, 174 
Methyl-blue in corneal ulcers, 383 
Nitric acid, as a caustic for phagedenic 

ulcers, or a solution (TO, 5 to 30 to the 

ounce [0.3-3.0 : 30.0]), locally applied to 

indolent types, 394 
Ointment of lead carbonate, as a dressing, 

352 
Potassium permanganate (gr. 60 to the 

pint [4.0 : 480), as an antiseptic wash, 

430 
Precipitated carbonate of calcium, as a dry 

dressing, 170 
Scarlet red in leg ulcers and syphilitic 

ulcers in from 2 to 8 per cent, ointment, 

479 
Silver nitrate, by injection, for rectal and 

cecal ulcers, 391 



Sulphuric acid, sometimes used as an 
escharotic in slow ulcers, 502 

Tannic acid, useful locally, in indolent 
ulcers, 509 

Tincture of iodine, useful in leg ulcers, 328 

Unna's dressing, 535 

UNCINARIASIS. 

Aspidium, a valuable remedy in, 140 

Beta-naphthol valuable in, 151 

Oil of chenopodium often even better than 

thymol, 191 
Thymol is best remedy, 515 

UREMIA, 953 

Amyl nitrite to combat convulsions, 954 

Aromatic spirit of ammonia and Hoff- 
mann's anodyne are valuable if heart is 
weak, 954 

Atropine, useful in pulmonary edema, 954 

Bromides for convulsions, 954 

Chloral and chloroform for convulsions, 
195, 954 

Dry cups over bases of both lungs in 
threatened pulmonary edema, 954 

Elaterium or elaterin, to aid elimination of 
poison by the bowel, 268, 953 

Ether, given by the mouth or hypodermic- 
ally, 283, 954 

Heroin, for dyspnea, 305 

Hot pack, 953 

Hypodermoclysis, 601, 954 

Nitroglycerin, to increase the urinary flow 
when arterial tension is high, 954 

Pilocarpine, gr. | (0.008), with strychnine 
gr. ^o (0.0012), to increase action of the 
skin, 445, 953 

Spinal puncture, 621 

Strychnine, followed by digitalis, for heart 
failure, 954 

Transfusion of salt solution of great value, 
614, 954 

Venesection, very useful, 614, 954 

URIC-ACID DIATHESIS. 

Acetate of potassium, 453 
Lime-water, 174 
Mineral waters, 622 

Piperazine in the dose of 15 grains (1.0) a 
day in 1 pint (480.0) of water, 447 

URTICARIA. 

Calcium chloride, to prevent, 171 
Magnesium carbonate often of value, 359 

UTERINE INERTIA. 

Pituitary gland in slow labor due to feeble- 
ness, 450 
Quinine not of great value, 225 

UVULA (RELAXED). 

Capsicum, tincture of, and glycerin, equal 

parts, as a gargle, 185 
Kino, as a gargle, 346 

VAGINITIS. 

Quercus, used as an astringent injection, 

462 
Silvol, 484 



INDEX OF DISEASES AND REMEDIES 



1037 



VITREOUS DISEASE, 954 

Antisyphilitic treatment, if due to syphilis, 

954 
Electric bath cabinet, 954 
Galvanism, 954 
Pilocarpine, hypodermically, in opacitieso 

444, 954 

VOMITING, 955 

Acetanilide, very useful, 69, 956 
Allium-juice, m 2 to 5 (0.12-0.3), useful in 

nervous vomiting, 87 
Arsenic, in vomiting of pregnancy, and of 
hand-fed babies and of drunkards, 123, 
957 
Bismuth and aconite may be of service, 

prescription for, 154, 956 
Brandy poured on cracked ice, very useful 

81, 956 , 

Bromide of potassium effervescing, 161 
Bromide of sodium, with laudanum, as a 

rectal injection, 956 
Calomel, 377 
Cerium oxalate often used instead of, or 

combined with bismuth, 191 
Chloretone, if due to irritation, and after 

etherization, 197, 956 
Chloroform, TU 1 to 2 (0.06-0.12), in water, 

957 
Cloves, oil of, sometimes controls, 232 
Cocaine or aconite, if due to hyperexcita- 

bility of stomach, 237, 956 
Corpus luteum has given good results in 

vomiting of early pregnancy, 250 
Enemas, partially digested, if vomiting is 

incoercible, 958 
Faradism sometimes gives relief, 957 
Fowler's solution, gtt. \ to 1 (0.03-0.06) 
every two hours, useful in nausea follow- 
ing debauch, 82, 957 
Hydrochloric acid TH, 5 to 15 (0.3-1.0), in 
water, every two hours, in alcoholic 
nausea, 312, 957 
Hydrocyanic acid, dilute, Tfl. 2 to 5 (0.1- 

0.3), in water, 313, 957 
Ice-bag to nape of neck, lumbar region, or 

epigastrium, 957 
Iodine and phenol, TU 1 (0.06) of each in dr. 

2 (8.0) of water, 957 
Ipecac, in small doses, if due to gastric 
depression, vomiting of pregnancy, or in 
morning vomiting of drunkards, 333, 
334, 957 
Lavage, 616 
Levulose, by rectum, in cyclic or toxemic 

vomiting in children, 958 
Lime-water, added to milk, may relieve 

nausea, 174, 958 
Mustard plaster over stomach, useful in all 

cases, 957 
Nitroglycerin, very useful in some cases, 

397, 957 
Nux vomica, if due to gastric depression, 

prescription for, 957 
Opium when excessive, 416 
Peptonized milk, best food, 958 
Phenol or creosote, with bismuth, useful 
in acidity and fermentation, prescription 
for, 433, 956 
Podophyllin, useful in gastric depression 

and hepatic torpor, 451 
Seidlitz powder, often settles stomach, if 
due to constipation, 481 



Sodium bicarbonate by Murphy drip to 

prevent acidosis, 958 
Sodium bicarbonate in vomiting of acidosis 

958 
Vinegar fumes of service when inhaled, 71, 

956 

VOMITING OF PREGNANCY. 

Aconite as a nervous sedative, 75 

Arsenic may be tried, 123 

Bromide of potassium as an effervescing 
draught, or with opium, by enema, pre- 
scriptions for, 161 

Cerium oxalate, gr. 2 to 5 (0.12-0.3), in 
pill, every four or five hours, 191 

Cocaine, useful to decrease irritability, 237 

Corpus luteum, early, has given good 
results, 250 

Iodine, tincture of, largely used of late 
with good results, 329 

Ipecac wine, TU 1 (0.06), or powder, gr. 
i to i (0.008-0.015), useful in some 
cases, 334 

Menthol, very useful, 427 

Thyroid gland, gr. 5 (0.3) in early morning, 
followed by quiet and, if possible, by 
sleep, sometimes relieves, 518 

WARTS. 

Acetic and salicylic acids combined, 70 
Chromic acid (gr. 100 to the ounce [6.0 : 
30.0]), locally applied, to remove, 218 

i Fowler's solution, locally applied, 123 
Glacial acetic acid, useful to remove, 70 

i Mercuric nitrate solution, locally, 380 

I Nitric acid as a caustic, 394 

j Sulphuric acid, locally, 502 

j Trichloracetic acid, useful, 519 

WHOOPING-COUGH, 959 

i Amber, oil of, 92 

j Amyl nitrite, when paroxysms interfere 

with respiration, 102, 959 
j Antipyrine, gr. \ to 3 (0.03-0.2) every 
five hours, probably the best remedy, 
111, 959 

Belladonna, tincture of, TU 2 (0.12) twice 
a day, to child of one or two years, 147, 
959 

Benzine, 959 

Benzyl benzoate, 151 
\ Bromoform, prescription for, 164, 959 
! Bronchitis-tent to modify severity of at- 
tacks, 959 

Chloral, 195 

Chloride of gold and sodium have been 
recommended, 300 

Chloroform, a few whiffs, if paroxysms in- 
terfere with respiration, 209, 959 

Creosote, on wet cloths hung in the nursery, 
of value, 253, 606 
: Gelsemium. 296 

Hyoscyamus, probably better than bella- 
donna, 316 

Monobromated camphor, 179 

Potassium bromide in, 160 

Quinine (gr. 1 to the ounce [0.06 : 30.0]), in 
spray, useful; also of service in exposed 
children as a prophylactic, 225, 959 

Resorcinol, 1U 10 (0.6) of a 2| percent. 
solution, internally, or, better, in spray, 
463 



1038 



INDEX OF DISEASES AND DISEASES 



Silver nitrate (gr. § to 1 to the ounce [0.03- 
0.06 : 30.0]), in spray, used when stom- 
ach is empty, 392 

Zinc oxide, 535 

WORMS, 960 

Aspidium, very efficient against tape- 
worms, prescription for, 140, 960 

Azedarach, a useful remedy against round- 
worms, 141 

Calomel, should follow or precede all drugs 
used for tape-worms, 960 

Castor oil, or a saline purgative, should 
follow remedies for round-worms, 960 

Chenopodium, oil of, m 5 to 20 (0.3-1.3), 
on sugar, to remove round-worms, 191 

Chloroform should not be used against 
tape- worms, 213 

Matricaria, 363 

PeUetierine, gr. 3 to 5 (0.2-0.3), in cap- 
sule, best remedy against tape-worm, 
452, 960 

Pepo, ounce 2 (60.0), in confection against 
tape-worm, 426, 960 

Pomegranate, useful in tape-worm, 452, 
960 

Quassia injections, preceded by soap and 
water, most useful remedy against seat- 
worms, 461, 960 

Rue, should not be used against round- 
worms, 466 

Rules for diet preceding ta^niacides, 960 

Salicylic acid, gr. 8 (0.5) hourly, till gr. 40 
(2.6) are taken, against round-worms, 
or as an injection against seat-worms, 
prescription for, 471 

Santonin, gr. j to \ (0.015-0.03), in troches 
for child, against round-worms, 476, 960 

Spigelia, alone or, better, with senna, to 
remove round-worms, 491 

Thymol, gr. 5 to 40 (0.3-2.6), in capsule, 
for uncinariasis, 515, 960 

Turpentine and castor oil, equal parts, effi- 
cient, but somewhat dangerous, against 
tape-worm, 527 



WOUNDS. 

Acetanilide as a dusting-powder, 69 
Alcohol, very useful in contused wounds, 

81 
Camphor and phenol mixture useful over 

small wounds, 178 
Castor oil, with a few drops of balsam of 

Peru or oil of eucalyptus, excellent, 190 
Chloretone, with equal parts boric acid, as 

an antiseptic dressing, 198 
Collodion as an air-tight dressing for small 

wounds, 244 
Dakin's fluid, 541 
Dichloramine-T, the best wound dressing 

we have, 545 
Formidine as a dusting-powder, 291 
Hydrogen peroxide, a valuable cleansing 

preparation in infected wounds, 315 
Iodine, tincture, painted in wounds filled 

with dirt as an antiseptic, 328 
Iodol collodion, useful, 332 
Magnesium sulphate, saturated solution, 

an excellent dressing for wounds infected 

with streptococci, 361 
Oil of cinnamon, 230 
Orthoform as an antiseptic, 421 
Potassium permanganate (gr. 20 to 60 to 

the pint [1.3-4.0 : 480.0]), as an antisep- 
tic wash, 430 
Salicylic acid, 472 
Thymol, locally, 515 
Urotropin, useful in traumatisms of brain 

and cord to prevent infection, 306 

XANTHOMA. 

Carbon dioxide snow, 560 

YAWS. 

Arsphenamine (salvarsan), a specific, 130 

YELLOW FEVER. 

Cocaine of value as a stimulant and anti- 
emetic, 237 



